A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?
Place the client close to the nurses' station.
Cover the site with a stockinette dressing.
Administer a sedative.
Apply a soft mitten restraint.
The Correct Answer is D
A) Place the client close to the nurses' station:
While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.
B) Cover the site with a stockinette dressing:
Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.
C) Administer a sedative:
Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.
D) Apply a soft mitten restraint:
This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Administer prescribed insulin:
Administering insulin is an essential aspect of managing type 1 diabetes mellitus, but before administering insulin, it's crucial to assess the client's current blood glucose level to determine the appropriate insulin dosage. Administering insulin without knowing the client's blood glucose level could lead to hypoglycemia if the blood glucose level is already low.
B) Check the calibration of the glucometer:
While it's important to ensure that the glucometer is calibrated correctly for accurate blood glucose readings, this step can be performed after obtaining the client's blood glucose level. Checking the calibration of the glucometer does not directly address the immediate need to assess the client's blood glucose level.
C) Obtain the client's capillary blood glucose level:
This is the most appropriate action to take first when providing morning care to a client with type 1 diabetes mellitus. Assessing the client's blood glucose level allows the nurse to determine the client's current glycemic status and make informed decisions about subsequent care, including insulin administration and breakfast provision.
D) Provide the client's breakfast:
Providing breakfast is an important aspect of morning care for a client with diabetes, but it should be done after assessing the client's blood glucose level. Depending on the client's blood glucose level, the nurse may need to adjust the timing or composition of the breakfast to ensure optimal glycemic control.
Correct Answer is C
Explanation
A) Medication administration record:
While the medication administration record (MAR) is an essential component of the client's medical records and care plan, it may not be directly relevant to the transfer report between healthcare facilities. The MAR typically remains with the client's medical records and is not routinely included in transfer reports. However, information about the client's current medications and any changes in medication regimen may be communicated as part of the transfer report.
B) Name of facility social worker:
While the name of the facility's social worker may be important for ongoing coordination of care and support services, it is not typically included in the transfer report between healthcare facilities. Communication between social workers may occur separately as part of the transition planning process, but it is not a standard component of the transfer report.
C) Need for special equipment:
When transferring a client from one healthcare setting to another, such as from an acute care unit to a long-term care facility, it is crucial to communicate any specific needs or requirements the client may have, including the need for special equipment. This information ensures that the receiving facility is adequately prepared to meet the client's needs upon arrival and can arrange for the necessary equipment or resources to be available. Examples of special equipment may include mobility aids (wheelchair, walker), assistive devices (hearing aids, oxygen concentrators), or specialized medical equipment (wound care supplies, catheters).
D) Health insurance information:
Health insurance information, including details about the client's coverage, billing, and insurance provider, is essential for financial and administrative purposes but may not be directly relevant to the transfer report between healthcare facilities. However, if specific insurance requirements or authorizations are necessary for the client's care at the receiving facility, this information should be communicated as part of the transfer process.
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