A nurse is caring for a 24-year-old female client who was admitted to the emergency unit following a horseback riding accident.
Increase the propofol infusion
Assess the client's pain
Notify the social worker the client is awake
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client’s decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : B,F,G,H
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Lathering using a circular movement is an effective handwashing technique. This method ensures thorough coverage of all surfaces of the hands, including areas that are often missed, such as between the fingers and under the nails. The friction generated by the circular motions helps dislodge dirt, bacteria, and viruses from the skin. Proper lathering is a crucial step in reducing the microbial load on the hands and preventing the spread of infections.
Choice B rationale
Turning the water off using bare hands contaminates the hands after they have been washed. This action can reintroduce bacteria or viruses from the faucet handle back onto the clean hands, negating the benefits of handwashing. Proper hand hygiene protocol recommends using a paper towel or elbow to turn off the water to maintain the cleanliness achieved by washing. This step is critical in breaking the chain of infection transmission.
Choice C rationale
Washing hands for a total of 20 seconds is in line with the recommended guidelines from health organizations like the CDC. This duration is considered sufficient to effectively remove soil, dirt, and transient microorganisms from the skin. It allows enough time for the soap to act on contaminants and for mechanical action to dislodge them. Adhering to this time frame is an essential component of effective hand hygiene practices.
Choice D rationale
Holding hands below the elbows when rinsing ensures that water flows from the wrists down to the fingertips, effectively washing away soap and contaminants. This technique prevents recontamination of the hands by keeping the direction of water flow from the cleanest to the dirtiest areas. Proper rinsing is a key aspect of hand hygiene, ensuring that all soap residues, along with any remaining microorganisms, are thoroughly removed.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.
Choice B rationale
Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.
Choice D rationale
Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.
Choice C rationale
Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.
Choice E rationale
Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.
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