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 A
Explanation
A. Iron:
Function: Iron is essential for the formation of hemoglobin, a protein in red blood cells that carries oxygen from the lungs to the rest of the body. It is vital for oxygen transport and overall cellular function.
Relevance: Iron deficiency can lead to anemia, characterized by reduced oxygen-carrying capacity of the blood, resulting in fatigue, weakness, and other symptoms.
B. Magnesium:
Function: Magnesium is involved in various cellular processes, including muscle and nerve function, blood glucose control, and bone health.
Relevance: While magnesium has important functions in the body, it is not directly involved in the transport of oxygen like iron.
C. Phosphorus:
Function: Phosphorus is a key component of DNA, RNA, and ATP, playing a role in energy metabolism, bone health, and acid-base balance.
Relevance: While important for cellular processes, phosphorus is not specifically linked to the transport of oxygen.
D. Potassium:
Function: Potassium is crucial for maintaining proper fluid balance, nerve impulses, and muscle contractions.
Relevance: Potassium is not directly involved in the transport of oxygen; its primary functions are related to electrolyte balance and cellular activities.
Correct Answer is A
Explanation
A. Proteinuria:
Minimal change nephrotic syndrome is characterized by increased permeability of the glomerular filtration barrier, leading to proteinuria. The loss of proteins, especially albumin, in the urine is a key feature.
B. Hypocalcemia:
Hypocalcemia is not typically associated with MCNS. In fact, the loss of proteins, including albumin, in the urine can lead to decreased oncotic pressure in the blood vessels, resulting in edema. However, calcium levels are usually within the normal range.
C. Hyperalbuminemia:
This is not a characteristic finding in minimal change nephrotic syndrome. In fact, the condition is associated with hypoalbuminemia due to the loss of albumin in the urine.
D. Positive for Ketones:
Ketones are not typically associated with minimal change nephrotic syndrome. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or starvation.
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