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:

Inflating the catheter's balloon is done after proper placement to secure the catheter in the bladder. It should not be done when there is resistance and no urine flow.

Choice B Reason:

Twisting the catheter gently is correct. Resistance during catheter insertion may indicate the catheter is encountering an obstruction or is misaligned. Gently twisting the catheter can help navigate around obstructions or correct misalignment without causing trauma to the urethra.

Choice C Reason:

Applying lidocaine gel to the urethra is typically used for lubrication and to numb the urethra during catheter insertion, but it may not address the issue of resistance or lack of urine flow.

Choice D Reason:

Lowering the penis to a 45° angle is not a standard action in response to resistance during catheter insertion. Twisting the catheter gently is a more appropriate initial step.

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 inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?

Correct Answer is B

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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