A nurse is caring for a patient who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied.
Which of the following statements by the nurse is appropriate?
“I will call the doctor and get the prescription.”.
“I will cover the catheter so he cannot see it.”.
“Let me provide more stimulation in his environment.”.
“Let’s wait until tonight to see if he continues this behavior.”.
The Correct Answer is A
Choice A rationale
The nurse should prioritize the safety of the patient. If a patient is frequently attempting to remove his feeding tube, it could lead to complications such as infection or injury. Therefore, the nurse might need to consider using a restraint as a last resort. However, it’s important to note that restraints should only be used when all other alternatives have been explored and failed. These alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.
Choice B rationale
Covering the catheter so the patient cannot see it might not be effective if the patient is aware of its presence and is determined to remove it. This approach does not address the underlying issue and may not prevent the patient from attempting to remove the feeding tube.
Choice C rationale
Providing more stimulation in the patient’s environment might be helpful in some cases, but it may not prevent the patient from attempting to remove the feeding tube. The effectiveness of this approach would depend on the specific circumstances and the patient’s condition.
Choice D rationale
Waiting until tonight to see if the patient continues this behavior could potentially put the patient at risk. If the patient is frequently attempting to remove the feeding tube, immediate action may be necessary to ensure the patient’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1 is: The prescribed dose is 100 mcg and each tablet contains 50 mcg.
Step 2 is: Divide the prescribed dose by the amount per tablet. So, 100 mcg ÷ 50 mcg/tablet. Step 3 is: The result is 2 tablets.
Correct Answer is D
Explanation
Choice A rationale
The prone position, which involves lying flat on the stomach, is not typically recommended for a child with respiratory failure due to pneumonia. While prone positioning can be beneficial in
certain cases of severe acute respiratory distress syndrome, it does not generally allow for maximal lung expansion.
Choice B rationale
The supine position, which involves lying flat on the back, is not typically recommended for a child with respiratory failure due to pneumonia. This position can make it more difficult for the lungs to expand fully, potentially worsening respiratory distress.
Choice C rationale
The side-lying position is not typically recommended for a child with respiratory failure due to pneumonia. While this position can be comfortable for resting, it does not generally allow for maximal lung expansion.
Choice D rationale
The upright position is typically recommended for a child with respiratory failure due to pneumonia. Sitting upright can help to maximize lung expansion and improve oxygenation.
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