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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A.Adequate protein intake is essential for skin repair and maintaining skin integrity. Protein helps in the healing process, supports the immune system, and strengthens the skin, making it more resistant to breakdown. This is a crucial intervention for preventing pressure ulcers and promoting overall skin health in older adults.

B.Massaging bony prominences is not recommended as it can cause friction and damage to already vulnerable skin, increasing the risk of skin breakdown rather than preventing it. Gentle repositioning is preferred to relieve pressure.

C.Clients at risk for skin breakdown should typically be repositioned at least every 2 hours, not every 3 hours, to relieve pressure and reduce the risk of developing pressure ulcers. Therefore, this option is not ideal as stated.

D.While keeping the skin dry is important, cornstarch is not recommended because it can cake and cause friction, which may lead to skin breakdown. Using moisture-wicking products or barrier creams is more appropriate for maintaining skin dryness and integrity.

A. Fluid volume overload B. Kidney stones C. Dermatitis D. Hypoglycemia

Correct Answer is C

Explanation

A. Fluid volume overload:
Explanation: Fluid volume overload is not typically associated with urinary incontinence. It is more commonly linked to conditions affecting the heart and kidneys.

B. Kidney stones:
Explanation: Kidney stones are not directly related to urinary incontinence. Kidney stones may cause pain, hematuria (blood in urine), and changes in urinary frequency.

C. Dermatitis:
Explanation: This is correct. Urinary incontinence can lead to skin irritation and dermatitis, especially if the skin is constantly exposed to urine. Keeping the perineal area clean and dry is important to prevent dermatitis.

D. Hypoglycemia:
Explanation: Hypoglycemia is not typically associated with urinary incontinence. It is more related to low blood sugar levels and is not a direct consequence of urinary incontinence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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