A nurse is caring for a client who is pulling on his NG tube. Which of the following actions should the nurse take first?

Administer a PRN sedative medication.

Determine the client's level of comfort.

Apply a soft-wrist restraint.

Document the client's behavior.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is A

Explanation

Choice A Reason:

Questioning the client about allergies before the procedure is appropriate. It is crucial to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is essential to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.

Choice B Reason:

Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.

Choice C Reason:

Evaluating the client for claustrophobia is appropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.

Choice D Reason:

Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.

A. Request a medication reconciliation form from the pharmacy. B. Ask the client if she received the 1700 medication. C. Contact the previous nurse to determine if the client received the medication. D. Administer the medication and document the current time.

Correct Answer is C

Explanation

Choice A Reason:

Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.

Choice B Reason:

Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.

Choice C Reason:

Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.

It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.

Choice D Reason:

Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.

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A nurse is caring for a client who is pulling on his NG tube. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

Correct Answer is A

Explanation

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

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A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

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