A nurse is caring for a patient 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 call the doctor and get the prescription.”.

“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.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse should prioritize the safety of the patient. If a patient is frequently attempting to remove his feeding tube, it could lead to complications such as infection or injury. Therefore, the nurse might need to consider using a restraint as a last resort. However, it’s important to note that restraints should only be used when all other alternatives have been explored and failed. These alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications.
Choice B rationale
Covering the catheter so the patient cannot see it might not be effective if the patient is aware of its presence and is determined to remove it. This approach does not address the underlying issue and may not prevent the patient from attempting to remove the feeding tube.
Choice C rationale
Providing more stimulation in the patient’s environment might be helpful in some cases, but it may not prevent the patient from attempting to remove the feeding tube. The effectiveness of this approach would depend on the specific circumstances and the patient’s condition.
Choice D rationale
Waiting until tonight to see if the patient continues this behavior could potentially put the patient at risk. If the patient is frequently attempting to remove the feeding tube, immediate action may be necessary to ensure the patient’s safety.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Raised toilet seats are not a safety risk for older adults. In fact, they can help prevent falls in the bathroom by reducing the distance an individual has to move to sit down and stand up from the toilet.
Choice B rationale
Throw rugs are a safety risk for older adults. They can easily cause tripping and falling, especially if the edges are not secured.
Choice C rationale

A water heater temperature of 54.4°C (130° F) is a safety risk. Water at this temperature can cause burns, especially in older adults who may have decreased sensitivity to heat.
Choice D rationale
Bathtubs with rails are not a safety risk for older adults. Rails can provide support and stability when getting in and out of the bathtub, reducing the risk of falls.
Choice E rationale
Electric cords behind furniture are a safety risk. They can be a tripping hazard and can also pose a fire risk if they are damaged.

A. A client who has community-acquired pneumonia with copious respiratory secretions B. A client who has AIDS and is coughing up blood C. A client who has Guillain-Barré syndrome and is on a ventilator D. A client who has bronchitis and a tracheostomy

Correct Answer is A

Explanation

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

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A nurse is caring for a patient 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?

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A nurse is caring for a patient 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?