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. 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.

A. Pulse oximetry reading of 95% B. Decreased depth of respirations C. Flaring of the nostrils D. Respiratory rate of 16/min

Correct Answer is C

Explanation

A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.

B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.

C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.

D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.

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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 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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Correct Answer is C

Explanation

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