A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

Choice A Reason

Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.

Choice B Reason

Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.

Choice C Reason

Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.

Choice D Reason

Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.

Choice A Reason

“Tube drainage should be rust-colored.” This statement is incorrect. Normal NG tube drainage is typically greenish-yellow due to bile or clear if it is from the stomach. Rust-colored drainage could indicate bleeding and should be reported immediately.

Choice B Reason

“Nutrition will be provided through the tube.” This statement is incorrect. While NG tubes can be used for feeding, in the context of a postoperative colectomy, the primary purpose of the NG tube is usually to decompress the stomach and prevent nausea and vomiting. Enteral feeding is typically done through a different type of tube, such as a nasojejunal tube.

Choice C Reason

“The tube decreases pressure within the stomach.” This is the correct statement. An NG tube is often used postoperatively to decompress the stomach, which helps to reduce pressure, prevent vomiting, and allow the gastrointestinal tract to heal.

Choice D Reason

“The tube should be irrigated with sterile water.” This statement is partially correct but needs context. NG tubes should be irrigated to maintain patency, but the type of solution (sterile water, saline) can vary based on hospital protocol. The primary focus here is on the purpose of the NG tube rather than the irrigation technique.