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 B

Explanation

Choice A Reason:

Keep her arms at the sides of her body with her hands in a relaxed position is wrong. Keeping the hands in a relaxed position at the sides of the body may increase the risk of accidental contact with non-sterile surfaces.

Choice B Reason:

Interlock her fingers and hold her hands away from her body above her waist is wright. Interlocking fingers and holding hands above the waist may increase the risk of accidental contact with non-sterile surfaces.

Choice C Reason:

Clasp her hands together in a relaxed position behind her body at her waist is wrong. This positioning helps maintain sterility by keeping the hands away from potential contaminants and below the waist level. Placing the hands behind the body avoids accidental contact with non-sterile surfaces or objects.

Choice D Reason:

Place one hand over the other against the part of the gown covering her upper body is wrong. Placing hands on the gown covering the upper body may lead to contamination, as the gown is considered non-sterile on the outside. The hands should be kept in a position that minimizes the risk of contact with non-sterile surfaces.

A. Set the maximum water heater temperature to 54.4° C (130° F). B. Paint the edges of steps for contrast. C. Secure extension cords across walkways. D. Use 40-watt bulbs to light hallways.

Correct Answer is B

Explanation

Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.

Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.

Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.

Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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