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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying the pulse oximeter probe to the toe might not provide an accurate reading if the client has poor peripheral circulation. Additionally, thickened toenails can interfere with the reading.
Choice B rationale
Edema in the hands can affect the accuracy of a pulse oximeter reading. The probe might not fit properly or provide a reliable reading if the finger is swollen.
Choice C rationale
Applying the pulse oximeter probe to a skin fold is not recommended. The probe needs to be placed on a relatively flat, thin area of skin to accurately measure oxygen saturation.
Choice D rationale
The earlobe is a suitable alternative site for pulse oximetry if the fingers and toes are not viable options. The earlobe is typically less affected by peripheral vasoconstriction, which can occur with hypothermia, certain medications, and certain diseases. Therefore, Choice D is the correct answer.
Correct Answer is ["2 ."]
Explanation
Step 1: Identify the prescribed dose and the available dose. The prescribed dose is 500 mg and the available dose is 250 mg per tablet.
Step 2: Use the formula for calculating the number of tablets: (Prescribed dose ÷ Available dose) = Number of tablets.
Step 3: Substitute the values into the formula: (500 mg ÷ 250 mg/tablet) = 2 tablets. So, the nurse should administer 2 tablets.
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