A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

Choice A Reason:

Administering sedative medication should not be the first action. It is important to assess the client's level of comfort and understand the reason for pulling on the NG tube before considering sedation. Sedation may mask underlying issues, and the goal is to address the cause of the behavior.

Choice B Reason:

Assessing the client's level of comfort is the priority. Understanding the reason for pulling on the NG tube is crucial before implementing interventions. The client may be experiencing pain, discomfort, anxiety, or another issue that needs to be addressed.

Choice C Reason:

Applying a restraint should be a last resort and is not the initial action. Restraints are used to ensure safety when other measures have failed. The priority is to address the underlying cause and promote comfort without resorting to restraint.

Choice D Reason:

Documenting the client's behavior is important for the medical record, but it comes after assessing and addressing the immediate needs of the client. Understanding the context and reasons for the behavior is crucial for accurate documentation.

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.