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 A
Explanation
Choice A reason : Reducing stimuli is crucial for a patient emerging from a coma, especially after a traumatic brain injury (TBI). Excessive sensory input can overwhelm the patient's already compromised neurological state. The goal is to provide a calm and controlled environment to prevent overstimulation, which can lead to increased intracranial pressure (ICP), agitation, and delayed recovery. Interventions may include minimizing noise, dimming lights, and limiting the number of visitors. It's important to tailor the level of stimuli to the individual patient's response and recovery stage.
Choice B reason : Darkening the room can be part of reducing stimuli, but it is not the sole intervention needed. While a darker environment may help some patients rest, it is not universally applicable and should be considered as one aspect of an overall strategy to reduce stimuli. The nurse must assess the patient's individual needs and responses to determine if darkening the room is beneficial.
Choice C reason : The application of restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and disorientation, potentially leading to self-injury or interference with medical devices. The use of restraints requires careful consideration, adherence to protocols, and often legal documentation. Non-pharmacological interventions and environmental modifications should be attempted first to manage restlessness.
Choice D reason : The administration of opioids is not typically indicated solely for restlessness in patients emerging from a coma. Opioids can depress the central nervous system, potentially masking neurological assessments and delaying recovery. They are primarily used for pain management. If restlessness is due to pain, then appropriate analgesia, including opioids, may be considered, but the underlying cause of restlessness should be thoroughly assessed and treated.
Correct Answer is C
Explanation
Choice A reason : White beans do not have a significant interaction with warfarin. They are a good source of protein and fiber and can be included in the diet unless otherwise contraindicated.
Choice B reason : Cantaloupe does not interact significantly with warfarin and can be consumed as part of a balanced diet. It is rich in vitamins and hydration.
Choice C reason : Cabbage contains vitamin K, which can interfere with the effectiveness of warfarin. Vitamin K is essential for blood clotting, and warfarin works by inhibiting the effects of this vitamin. Therefore, patients on warfarin are advised to maintain a consistent intake of vitamin K and avoid sudden increases in foods high in this nutrient.
Choice D reason : Green beans have a moderate amount of vitamin K but are not typically restricted for patients on warfarin. It is important for patients to maintain a consistent intake of vitamin K; thus, they should not make significant changes to their diet without consulting their healthcare provider.
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