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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6 "]
Explanation
To calculate the number of capsules the nurse should administer in a 24 hr period, the nurse should first divide the prescribed dose by the available dose.
This gives 750 mg / 375 mg = 2 capsules.
Then, the nurse should multiply the number of capsules per dose by the number of doses per day.
This gives 2 capsules x 3 doses = 6 capsules.
Therefore, the nurse should administer 6 capsules of metronidazole in a 24 hr period to the client who has bacterial vaginosis.
Correct Answer is D
Explanation
A. Devout practitioners of Buddhism prefer a ritual bath prior to burial.
Explanation: In Buddhism, the funeral customs can vary widely depending on the cultural and regional practices. Some Buddhists may prefer cremation, while others may choose burial. There isn't a strict requirement for a ritual bath, and practices can differ.
B. Devout practitioners of Judaism prefer to be buried 5 days after death.
Explanation: In Judaism, there is a tradition of burying the deceased as soon as possible, ideally within 24 hours. Waiting for 5 days is not consistent with Jewish burial practices.
C. Devout practitioners of Hinduism prefer to be buried after death and not cremated.
Explanation: In Hinduism, cremation is a common practice. Hindus believe in the cycle of reincarnation, and cremation is seen as a way to release the soul from the body. Burial is not a typical practice in Hinduism.
D. Devout practitioners of Islam prefer to have their heads turned toward Mecca at death.
Explanation: In Islam, it is a common practice to bury the deceased with their right side facing the Qiblah, which is the direction of the Kaaba in Mecca. This is part of the Islamic funeral rites.
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