A physician orders a nasogastric (NG) tube for a young adult diagnosed with end-stage ovarian cancer and suspected of having a bowel obstruction. The newly hired nurse explains the procedure and rationale for NG tube placement. The client refuses to consent to NG tube placement, stating, "I would rather keep vomiting than have the tube in my nose." Following the American Nurses Association Code of Ethics for Nurses, what should the nurse do next?
Delegate the NG tube placement to a more experienced nurse.
Make a referral to Social Services related to body image disturbance.
Seek the client's spouse for consent to the procedure.
Document the client's wishes and notify the physician.
The Correct Answer is D
Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.
Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.
Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.
Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.
Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.
Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.
Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².
Correct Answer is D
Explanation
Choice A reason : Tarry stools, also known as melena, can be a sign of gastrointestinal bleeding, which may occur in cirrhosis due to the development of esophageal varices. However, it is not a direct symptom of cirrhosis itself but rather a complication that can arise from the condition¹.
Choice B reason : Blood in the urine is not a typical finding associated with cirrhosis. While cirrhosis can lead to problems with kidney function, hematuria is not a direct symptom of liver disease and may indicate other urological conditions¹.
Choice C reason : Moist skin is not commonly associated with cirrhosis. Patients with cirrhosis often experience skin changes, but these typically include jaundice, bruising, and spider angiomas, not increased moisture of the skin¹.
Choice D reason : Spider angiomas are a common finding in cirrhosis. They are small, spider-like capillaries visible under the skin and are caused by the increased estrogen levels that occur due to the liver's inability to metabolize hormones properly. They are most often found on the face, neck, upper chest, and arms¹².
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