A confused patient refuses his medication. What is the nurse's first response?

Agree with the patient's decision and document it in his chart.

Discreetly hide the medication in the patient's favorite Jell-O.

Inform the patient that he must take the medication whether he wants to or not.

Educate the patient about the importance of the medication.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Agreeing and documenting without further action ignores the opportunity to promote patient safety.
B. Hiding medication in food without consent is unethical and violates patient rights.
C. Forcing medication is not appropriate and violates autonomy.
D. The first response is to educate the patient about the purpose and importance of the medication to promote understanding and encourage cooperation, even in cases of confusion.

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Correct Answer is D

Explanation

Rationale:
A. Petroleum-based lubricants should never be used because they can cause respiratory complications if aspirated. Water-soluble lubricant is recommended.
B. If the patient begins to cough, the nurse should stop the procedure immediately and check placement, as the tube may have entered the airway. Giving water at that time increases the risk of aspiration.
C. Sterile gloves are not required; NG tube insertion is a clean procedure, not a sterile one.
D. Rotating the tube 180 degrees while advancing as the patient swallows facilitates smooth passage into the esophagus, reducing discomfort and preventing coiling in the pharynx.

A. A 22-year-old adult. B. A 50-year-old patient. C. A 2-year-old child. D. An 80-year-old patient.

Correct Answer is C

Explanation

Rationale:
A. A 22-year-old adult would typically have IV access placed in the veins of the upper extremities (hand or forearm), not the foot.
B. A 50-year-old patient would not be an appropriate candidate for a foot IV, as peripheral veins in the arms are preferred and safer.
C. A 2-year-old child is correct because the dorsal venous plexus of the foot is often used in infants and young children when veins in the hands or arms are small, fragile, or difficult to access.
D. An 80-year-old patient would be at increased risk of poor circulation and delayed healing in the feet, making this site inappropriate.

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A confused patient refuses his medication. What is the nurse's first response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following would demonstrate appropriate knowledge when inserting a nasogastric (NG) tube?

Correct Answer is D

Explanation

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

Correct Answer is C

Explanation

Which of the following describes the correct method for applying a patient's eye ointment?

Which of the following is the correct way to determine the appropriate length of nasogastric tube insertion for an adult patient?

The nurse is assessing the patient for signs and symptoms of fluid volume excess. Which of the following would indicate that the patient is experiencing this complication and should be reported? (Select all that apply.)

Rebecca RPN is changing Mrs. Taurine's tracheostomy for the first time. Upon insertion of the suction catheter, Mrs. Taurine begins to cough. What is Rebecca's most appropriate action?

The nurse is having difficulty reading a prescriber's order for a medication. The nurse knows that the prescriber is very busy and does not like to be called. What should the nurse do?

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?

A nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the needed length of the tube to be inserted, the nurse measures what length?