A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?
"I will cover the catheter so he cannot see it."
"Let me provide more stimulation in his environment."
"Let's wait until tonight to see if he continues this behavior."
"I will call the doctor and get the prescription."
The Correct Answer is D
A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.
B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.
C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.
D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dry mucous membranes:
Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor:
Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis:
Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria:
Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
Correct Answer is A
No explanation
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