A nurse is educating a parent of an infant diagnosed with gastroesophageal reflux. Which statement from the parent shows they have understood the teaching?

Choice A rationale

While it is within the nurse’s scope of practice to communicate with the doctor regarding the patient’s condition, applying restraints should not be the first course of action when a patient frequently tries to remove their IV catheter. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice B rationale

This is the correct response. Covering the catheter so the patient can’t see it may help to reduce the patient’s urge to remove it. This is a non-invasive intervention that respects the patient’s autonomy while also ensuring their safety.

Choice C rationale

Waiting until nighttime to see if the patient continues the behavior may not be the best course of action. If the patient is frequently trying to remove their IV catheter, it is important to address the issue promptly to prevent potential harm.

Choice D rationale

Applying restraints immediately is not the best course of action. Restraints should only be used as a last resort when all other interventions have failed and the patient’s safety is at risk.

Choice A rationale

The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.

Choice B rationale

Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.

Choice C rationale

Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.

Choice D rationale

Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.