A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Provide diversionary activities for the client.

Assist the client with toileting at frequent intervals.

Involve the family in the client’s care.

Explain to the client that he will be restrained if he does not stop pulling on his NG tube.

Use an electronic bed alarm device.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

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Correct Answer is C

Explanation

Choice A rationale

Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.

Choice B rationale

Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.

Choice C rationale

Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.

Choice D rationale

Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.

A. Avoid handwashing after eating. B. Avoid foods prepared with tap water. C. Avoid eating meat. D. Avoid covering sores with bandages.

Correct Answer is B

Explanation

Choice A rationale

Avoid handwashing after eating. This statement is incorrect. Handwashing is a critical preventive measure to reduce the risk of viral hepatitis, especially after eating or using the restroom.

Choice B rationale

Avoid foods prepared with tap water. This statement is correct. In areas where the water supply may be contaminated, it is essential to avoid foods prepared with tap water to reduce the risk of viral hepatitis, particularly hepatitis A, which can be transmitted through contaminated food and water.

Choice C rationale

Avoid eating meat. This statement is incorrect. While it is essential to ensure that meat is cooked thoroughly to prevent foodborne illnesses, avoiding meat altogether is not a specific preventive measure for viral hepatitis.

Choice D rationale

Avoid covering sores with bandages. This statement is incorrect. Covering sores with bandages can help prevent the spread of infections, including viral hepatitis, by reducing the risk of contact with infectious fluids.

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)