A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Engage the client in a repetitive activity as a distraction.

Place the client in a seclusion room.

Apply wrist restraints to the client.

Administer PRN haloperidol IM to the client

Answer and Explanation

The Correct Answer is A

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it: This action is appropriate as long as the specimen is labeled correctly and stored at the correct temperature. Proper handling of specimens is essential for accurate testing and does not represent an infection control hazard.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill: This action is appropriate for cleaning a contaminated surface. Chlorhexidine is an effective disinfectant for blood spills. Therefore, this action does not represent an infection control hazard.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster: While alcohol-based antiseptics are effective for most pathogens, varicella zosteris primarily spread through direct contact and airborne transmission. It is recommended to wash hands with soap and water after caring for a patient with varicella zoster, especially if hands are visibly soiled. This action may not adequately control the infection hazard.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture: This action is appropriate as long as sterile technique is maintained. Using sterile saline for irrigation is standard practice to minimize the risk of introducing pathogens before specimen collection. Therefore, this action does not represent an infection control hazard.

Correct Answer is ["3"]

Explanation

To calculate the volume (mL) that the nurse should administer, we can follow these steps:

Convert the weight from pounds to kilograms.

1 lb = 0.453592 kg
165 lb×0.453592 kg/lb≈74.843 kg

Calculate the total dose using the weight and prescribed dose:

Total Dose (units)=Dose per kg×Weight (kg)
Total Dose=8 units/kg×74.843 kg≈598.744 units

Determine the volume using the concentration of the available solution:

Volume (mL)=Total Dose (units)/Concentration (units/mL)
Volume =598.744 units/200 units/mL ≈ 2.994 mL

Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

Correct Answer is C

Explanation

A nurse is preparing to administer calcitonin 8 units/kg IM to a client who weighs 165 lb. Available is 200 units/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

A nurse is accessing computerized data about a client recently transferred to a step-down unit. Which of the following forms should provide the nurse with the most comprehensive client information?

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

A nurse is attending a quality improvement meeting. Which of the following actions should the nurse take first when initiating a quality improvement program to address health care-associated infections?

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

A nurse in a provider's office is collecting data from a client whose partner reports that the client stops breathing for 30-second intervals while sleeping at night. The nurse should recognize the client might need which of the following equipment for home use?

A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

A nurse is preparing to administer methotrexate 7.5 mg subcutaneous for a client who has rheumatoid arthritis. Available is methotrexate 15 mg/0.4 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)