A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Provide diversionary activities for the client.

Assist the client with toileting at frequent intervals.

Involve the family in the client’s care.

Explain to the client that he will be restrained if he does not stop pulling on his NG tube.

Use an electronic bed alarm device.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

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Correct Answer is C

Explanation

Choice A rationale

A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.

Choice B rationale

A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.

Choice C rationale

Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.

Choice D rationale

Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function

A. Insert a nasogastric (NG) tube. B. Ask the client about the precipitating events. C. Obtain vital signs. D. Complete a head-to-toe assessment.

Correct Answer is C

Explanation

Choice A rationale

Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.

Choice B rationale

Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.

Choice C rationale

Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.

Choice D rationale

Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Nursing Test Bank

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)