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. Discontinue supplements containing vitamin C 24 hr before the test. B. Place a thick layer of stool on the specimen card. C. Urinate prior to collecting the stool specimen. D. Refrain from consuming pork 7 days before the test.

Correct Answer is C

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr before the test is appropriate. This is not necessary for fecal occult blood testing. However, vitamin C supplements should be avoided before certain stool tests that use a chemical reaction involving guaiac.

Choice B Reason:

Placing a thick layer of stool on the specimen card is inappropriate. The client should apply a small amount of stool to the designated area on the specimen card. A thick layer is not required, and excess stool may interfere with the test.

Choice C Reason:

Urinating prior to collecting the stool specimen is appropriate. This instruction is important because it helps prevent contamination of the stool specimen with urine, which could potentially interfere with the accuracy of the test results.

Choice D Reason:

Refraining from consuming pork 7 days before the test is inappropriate. There is no need for the client to avoid consuming pork specifically for fecal occult blood testing. The instructions usually focus on dietary restrictions that could affect the presence of blood in the stool, such as avoiding red meat or certain medications.

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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 reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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