A nurse is caring for a patient who has dementia.
What intervention should the nurse take to minimize the risk of injury to the patient?

Use a bed exit alarm system.

Raise four side rails while the patient is in bed.

Apply one soft wrist restraint.

Dim the lights in the patient’s room.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

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Free Nursing Study Resources

Correct Answer is ["8"]

Explanation

Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.

Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.

Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.

A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication. C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

Correct Answer is A

Explanation

Choice A rationale

After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.

Choice B rationale

Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.

Choice C rationale

Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

Choice D rationale

Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

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A nurse is caring for a patient who has dementia. What intervention should the nurse take to minimize the risk of injury to the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["8"]

Explanation

A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.What should the nurse do next?

Correct Answer is A

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A nurse is caring for a patient who has dementia.
What intervention should the nurse take to minimize the risk of injury to the patient?