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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.
Choice B Reason:
Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.
Choice C Reason:
Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.
Choice D Reason:
Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.
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.
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