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.

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Correct Answer is ["300"]

Explanation

To calculate the infusion rate (mL/hr), you can use the following formula:

Infusion Rate (mL/hr)=Total Volume (mL)/Total Time (hr)

In this case:

Infusion Rate=1,800 mL/6 hr
Infusion Rate=300mL/hr

Therefore, the nurse should ensure the IV pump is set to deliver 300 mL/hr for the 0.9% sodium chloride infusion over 6 hours, rounded to the nearest whole number.

A. Base appraisals on peer review from other AP. B. Examine the agency's job description for AP. C. Gather information from clients regarding the AP. D. Review the AP's previous performance appraisal.

Correct Answer is C

Explanation

A. Base appraisals on peer review from other AP:

While peer input can provide valuable insights, it's important to gather feedback from various sources, including those who directly interact with the AP, such as clients and nurses.

B. Examine the agency's job description for AP:

The job description provides information about the expectations and responsibilities of the AP. However, performance appraisal should involve more than just a comparison to the job description.

C. Gather information from clients regarding the AP:

This is the correct answer. Clients can provide valuable feedback on the care and services they receive from the AP. Their perspective can contribute to a more comprehensive assessment of the AP's performance.

D. Review the AP's previous performance appraisal:

While reviewing previous appraisals can offer historical context, it's essential to gather current information to assess the AP's current performance and growth.

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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 is assisting in the care of a client who is to receive 0.9% sodium chloride 1,800 mL IV over 6 hr. The nurse should ensure the IV pump is set to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["300"]

Explanation

A nurse is asked by the unit manager to provide input for the performance appraisal of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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