A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
Assess the cause of the agitation.
Reassure the client that he or she is safe.
Restrain the client's hands.
Sedate the client immediately.
The Correct Answer is A
A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.
B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.
C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.
D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. PT/INR: PT/INR is used to assess clotting function and liver synthetic function but does not directly relate to the symptoms of lethargy and confusion.
B. Urea: Urea levels are related to kidney function and protein metabolism but do not directly explain the symptoms of encephalopathy.
C. Ammonia: Elevated ammonia levels in cirrhosis can lead to hepatic encephalopathy, which presents as lethargy and confusion. The liver is unable to convert ammonia to urea, leading to its accumulation in the blood.
D. Albumin: Albumin levels are important in assessing nutritional status and fluid balance in cirrhosis but do not directly cause lethargy and confusion.
Correct Answer is C
Explanation
A. A shunt will divert blood from the hepatic vein to the Inferior vena cava: This is not the correct pathway for a TIPS procedure.
B. A shunt will divert blood from the aorta to the inferior vena cava: This describes a different vascular pathway unrelated to TIPS.
C. A shunt will divert blood from the portal vein to the hepatic vein: TIPS (Transjugular Intrahepatic Portosystemic Shunt) is a procedure that creates a pathway between the portal vein and hepatic vein, reducing portal hypertension and preventing variceal bleeding.
D. A shunt will divert blood from the aorta to the hepatic vein: This is not the correct anatomical pathway for a TIPS procedure.
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