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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypervolemia is not typically associated with extensive burn injuries. Burn patients often experience hypovolemia due to fluid loss from the burn wounds.
Choice B rationale
Hyperkalemia is a common finding in patients with extensive burn injuries. The destruction of cells releases potassium into the bloodstream, leading to elevated potassium levels.
Choice C rationale
Low hemoglobin is not a typical finding in the initial phase of burn injury. Hemoglobin levels may decrease later due to blood loss or hemodilution.
Choice D rationale
Metabolic alkalosis is not commonly associated with extensive burn injuries. Burn patients are more likely to experience metabolic acidosis due to tissue hypoxia and lactic acid accumulation.
Correct Answer is C
Explanation
Choice A rationale
Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.
Choice B rationale
Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.
Choice C rationale
Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.
Choice D rationale
Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.
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