A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Provide a back rub at bedtime.

Leave the door to the client's room open slightly.

Apply wrist restraints to prevent wandering.

Administer a PRN sedative prescription.

Answer and Explanation

The Correct Answer is A

A. Provide a back rub at bedtime:

This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.

B. Leave the door to the client's room open slightly:

Leaving the door open may not prevent wandering and could potentially lead to safety issues.

C. Apply wrist restraints to prevent wandering:

Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.

D. Administer a PRN sedative prescription:

Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.

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Correct Answer is A

Explanation

A. When the client voided following catheter removal:

This information is crucial because it indicates the return of the client's ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

B. Color of the urine during catheter removal:

While the color of the urine during catheter removal may provide some insight into the client's urinary condition, it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

C. Time of the last dose of IV antibiotic administration:

While the timing of the last dose of IV antibiotic administration is important for managing the client's urinary tract infection, it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

D. Intake and output reports for the previous shift:

Intake and output reports are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. B. Send the UAP to be fitted for a particulate filter mask Immediately so the UAP can provide care to this client. C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client. D. Before changing assignments, determine which staff members have fitted particulate filter masks.

Correct Answer is C

Explanation

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:

This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:

This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:

This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.

D. Before changing assignments, determine which staff members have fitted particulate filter masks:

While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

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A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

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