A nurse is caring for a client who has dementia and wanders frequently. Which of the following actions should the nurse take?
Apply a motion sensor mat to the client's bed.
Move the overbed table away from the bed.
Raise all four side rails while the client is in bed.
Leave the television on in the client's room.
The Correct Answer is A
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Taking the medication right before eating breakfast is not an appropriate instruction, as it can reduce the absorption and effectiveness of alendronate, which is a bisphosphonate drug that inhibits bone resorption and increases bone density. The client should take the medication at least 30 min before eating or drinking anything other than water.
Choice B reason: Drinking milk with the medication is not an appropriate instruction, as it can interfere with the absorption and effectiveness of alendronate, which can bind to calcium and other minerals and form insoluble complexes that are excreted in feces. The client should avoid consuming dairy products or supplements that contain calcium, iron, magnesium, or aluminum for at least 30 min after taking the medication.
Choice C reason: Staying upright for 30 to 60 min after taking the medication is an appropriate instruction, as it can prevent esophageal irritation or ulceration that can be caused by alendronate, which can be corrosive to the mucosa if it remains in contact with it for too long. The client should not lie down or bend over until after their first food of the day.
Choice D reason: Chewing the tablets thoroughly is not an appropriate instruction, as it can increase the risk of esophageal irritation or ulceration that can be caused by alendronate, which can be abrasive to the mucosa if it is not swallowed whole with a full glass of water. The client should not crush, break, or dissolve the tablets in any liquid.
Correct Answer is A
Explanation
Choice A reason: Taking ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a false-positive result on a fecal occult blood screening test, as they can irritate the gastrointestinal mucosa and cause bleeding.
Choice B reason: Having a hemorrhoidectomy 1 year ago is unlikely to cause a false-positive result on a fecal occult blood screening test, as hemorrhoids are usually a source of bright red blood that can be seen with naked eye, not occult blood that requires chemical detection.
Choice C reason: Having a history of breast cancer is not related to a false-positive result on a fecal occult blood screening test, as breast cancer does not affect the gastrointestinal tract or cause bleeding in stool.
Choice D reason: Consuming citrus juice 3 days before the test is not likely to cause a false-positive result on a fecal occult blood screening test, as citrus juice does not contain any substances that can interfere with the chemical reaction of the test. However, consuming red meat, raw vegetables, vitamin C supplements, or iron supplements within 3 days before the test can cause false-negative results, as they can mask or degrade occult blood in stool.
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