A nurse is caring for a client who is pulling on his NG tube. Which of the following actions should the nurse take first?
Administer a PRN sedative medication.
Determine the client's level of comfort.
Apply a soft-wrist restraint.
Document the client's behavior.
The Correct Answer is B
Choice A Reason:
Administering sedative medication should not be the first action. It is important to assess the client's level of comfort and understand the reason for pulling on the NG tube before considering sedation. Sedation may mask underlying issues, and the goal is to address the cause of the behavior.
Choice B Reason:
Assessing the client's level of comfort is the priority. Understanding the reason for pulling on the NG tube is crucial before implementing interventions. The client may be experiencing pain, discomfort, anxiety, or another issue that needs to be addressed.
Choice C Reason:
Applying a restraint should be a last resort and is not the initial action. Restraints are used to ensure safety when other measures have failed. The priority is to address the underlying cause and promote comfort without resorting to restraint.
Choice D Reason:
Documenting the client's behavior is important for the medical record, but it comes after assessing and addressing the immediate needs of the client. Understanding the context and reasons for the behavior is crucial for accurate documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6 "]
Explanation
To calculate the number of capsules the nurse should administer in a 24 hr period, the nurse should first divide the prescribed dose by the available dose.
This gives 750 mg / 375 mg = 2 capsules.
Then, the nurse should multiply the number of capsules per dose by the number of doses per day.
This gives 2 capsules x 3 doses = 6 capsules.
Therefore, the nurse should administer 6 capsules of metronidazole in a 24 hr period to the client who has bacterial vaginosis.
Correct Answer is C
Explanation
Choice A Reason:
Discarding the vial with the remaining medication in the sharp container is inappropriate. This would result in unnecessary waste of the medication and could lead to increased healthcare costs.
Choice B Reason:
Having another nurse witness the disposal of the remaining medication is inappropriate. Witnessing the disposal is typically required for controlled substances, but in this situation, it's more appropriate to use the remaining medication with appropriate documentation.
Choice C Reason:
Drawing up the remaining 1 mg in a syringe and label it with the contents, date, and time is appropriate. This approach minimizes medication wastage and allows for appropriate documentation of the extra dose drawn up. However, it is crucial to label the syringe clearly with the contents, date, and time to avoid any potential errors or confusion. This labeled syringe can then be used for subsequent doses, as long as it remains within the medication's expiration period and adheres to institutional policies.
Choice D Reason:
Storing the vial in the client's medication drawer for future use is inappropriate. Keeping the vial for future use without appropriate documentation is not recommended, as it may lead to medication errors or confusion.
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