A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Engage the client in relaxation exercises.

Offer to sit with the client until she relaxes.

Administer a prescribed PRN analgesic.

Assist the client to a different position.

Answer and Explanation

The Correct Answer is D

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Gather materials to change soiled items only: Not indicated. The nurse should gather all necessary materials for the entire wound care procedure, not just for changing soiled items, to ensure the dressing change is performed efficiently and effectively.
Thoroughly clean wound using normal saline prior to redressing: Indicated. Proper wound cleaning with normal saline helps remove debris and reduce bacterial load, preparing the wound for the application of new dressings.
Place sterile gauze directly on wound bed: Not indicated. The wound care order specifies the use of anasept gel covered with foam dressing. Sterile gauze is not the appropriate dressing in this scenario.
Apply sterile gloves prior to changing: Indicated. Sterile gloves are necessary to maintain sterility and prevent infection during the dressing change procedure.
Apply sterile foam dressing over wound bed: Indicated. The orders specify the use of a foam dressing after applying anasept gel, which provides the necessary coverage and protection for the wound.
Maintain clean medical asepsis: Not indicated. While maintaining a clean environment is important, sterile technique (rather than clean medical asepsis) is required for this dressing change to prevent infection and promote healing in the wound bed.

A. Notify the information services department of the situation. B. Print electronic medical record (EMR) from the backup server. C. Identify information as a late entry in the record. D. Wait for notification that the system has been rebooted.

Correct Answer is A

Explanation

A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

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A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

Correct Answer is A

Explanation

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?