A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Determine the client's level of consciousness

Administer an anxiolytic medication.

Keep lights on in the client's room.

Encourage visits from family members.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.

Choice B Reason:

Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.

Choice C Reason:

Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.

Choice D Reason:

Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.

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Correct Answer is B

Explanation

Choice A Reason:

Wiping from the outer to the inner canthus is not necessary and may cause contamination.

Choice B Reason:

Apply pressure to the lacrimal punctum after administering the drops. After administering eye drops to a child, it is important to gently apply pressure to the lacrimal punctum (located in the inner corner of the eye) for about 1-2 minutes. This helps prevent systemic absorption of the medication and reduces the risk of it going into the nasopharynx and digestive system. The other options are not recommended:

Choice C Reason:

Positioning the child side-lying is not typically required for administering eye drops.

Choice D Reason:

Rinsing the eye with normal saline before administering the drops is not a standard practice and is not recommended unless there is a specific reason to do so, such as eye irritation or foreign body removal.

A. The surgeon B. The pharmacist C. The case manager D. The risk manager

Correct Answer is D

Explanation

Choice A Reason:

The surgeon is incorrect. Surgeons primarily focus on the surgical procedure itself and the immediate postoperative care related to the surgery. They may not have a direct role in medication management or overall postoperative care beyond the surgical site.

Choice B Reason:

The pharmacist is incorrect. While pharmacists play a vital role in medication management, they typically focus on dispensing medications, providing drug information, and ensuring proper dosages and administration. They may not be directly involved in assessing fall rates or postoperative outcomes.

Choice C Reason:

The case manager is incorrect. Case managers are responsible for coordinating a patient's care and ensuring that it meets their overall healthcare needs. They may not have the expertise or authority to investigate and address specific safety concerns related to medication use and fall rates.

Choice D Reason:

The risk manager is correct. When a nurse identifies an issue related to patient safety, such as an increased fall rate associated with a specific medication like zolpidem, it is important to report these findings to the risk manager. The risk manager is responsible for assessing and addressing issues related to patient safety and quality improvement within the healthcare facility. They can investigate the matter further, collaborate with other members of the healthcare team, and implement necessary changes or protocols to mitigate the risk and improve patient safety. Reporting such findings to the risk manager is a crucial step in ensuring patient safety and quality of care.

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A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings?

Correct Answer is D

Explanation

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