A nurse is caring for a client 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 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."

"I will call the doctor and get the prescription."

Answer and Explanation

The Correct Answer is D

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

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Correct Answer is B

Explanation

A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.

B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.

C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.

D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.

A. Explain alternatives to the procedure to the client. B. Discuss the risks of the procedure with the client. C. Confirm that the client is competent to sign for the procedure. D. Inform the client about what will occur during the procedure.

Correct Answer is C

Explanation

A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.

B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.

C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.

D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.

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A nurse is caring for a client 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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