A nurse is caring for a client who is mechanically ventilated and is agitated. The nurse notices the client attempts to reach the endotracheal tube. Which of the following actions should the nurse take?
Verify the alarm settings on the ventilator.
Turn on the television.
Obtain a prescription for a vest restraint.
Administer a sedative medication.
The Correct Answer is D
Rationale:
A. Verify the alarm settings on the ventilator: Ensuring alarms are properly set is a routine safety check but does not directly address the client's agitation or risk of self-extubation. It is important but not the priority action in this scenario.
B. Turn on the television: Providing distraction may help reduce mild anxiety but is insufficient for managing significant agitation in a mechanically ventilated client who may become dangerous to themselves if they pull out the endotracheal tube.
C. Obtain a prescription for a vest restraint: Physical restraints should be a last resort after attempting less restrictive methods. Using restraints without addressing the underlying cause of agitation (e.g., discomfort, anxiety, pain) can increase distress and injury risk.
D. Administer a sedative medication: Sedation is appropriate for a mechanically ventilated client who is agitated and at risk for self-extubation. Sedatives help ensure patient comfort, reduce anxiety, and promote ventilator synchrony while protecting the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Take a dose of loperamide each morning.": Loperamide is an antidiarrheal medication and is not appropriate for clients with constipation-predominant IBS (IBS-C). Using loperamide in these clients could worsen constipation.
B. "Increase your fluid intake to 1,000 milliliters per day.": A daily fluid intake of 1,000 milliliters (1 liter) is typically insufficient. Adequate hydration is essential for managing constipation, and clients are generally encouraged to consume at least 6 to 8 glasses (approximately 1.5 to 2 liters) of water daily to help soften stools and promote regular bowel movements.
C. "Take psyllium in the evening.": Psyllium is a soluble fiber supplement that can help alleviate constipation by increasing stool bulk and promoting bowel movements. Taking psyllium in the evening is appropriate, but it is crucial to take it with a full glass of water and maintain adequate hydration throughout the day to prevent potential side effects like bloating or gas.
D. "Consume a diet that is low in protein.": There is no specific recommendation for a low-protein diet in managing IBS-C. Dietary modifications for IBS-C typically focus on increasing soluble fiber intake and reducing fermentable carbohydrates (FODMAPs) rather than altering protein consumption.
Correct Answer is C
Explanation
Rationale:
A. The client's bed has a three-prong plug attached to the electrical cord: A three-prong plug provides grounding and is a standard safety feature. It helps prevent electric shock and is not considered a hazard.
B. A protective cover is inserted into an unused outlet: Outlet covers are recommended, especially in homes with children, to prevent accidental electrical shock. This is a safety measure, not a hazard.
C. An IV pump is plugged into an outlet near a sink: This is a safety hazard because electrical devices should not be used near water sources. The proximity to the sink increases the risk of electrical shock or short-circuiting if moisture contacts the outlet or device.
D. An electrical cord is coiled and secured to the floor: Coiling and securing cords can prevent tripping hazards and is generally acceptable as long as the cord is not damaged or covered in a way that could lead to overheating.
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