A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Turn on the bed alarm.

Maintain the bed in the lowest position.

Place the client in a vest restraint.

Administer a sedative.

Encourage the family to stay with the client.

Answer and Explanation

Correct Answer : A,B,E

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

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Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

A. Initiate a new IV line below the original insertion site. B. Discontinue the infusion. C. Raise the head of the bed. D. Obtain a culture from the area of the insertion site.

Correct Answer is B

Explanation

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

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A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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