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.”.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

A. There is slough on part of the wound area. B. There appears to be persistent reddening of the skin. C. There is full-thickness skin loss with a crater. D. There is a fluid-filled area under the skin.

Correct Answer is C

Explanation

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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?