A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?

Obtain a prescription for a sedative for the client.

Remove the clock and calendar from the client's room.

Provide distractions for the client during the day.

Raise all four side rails on the client's bed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining a prescription for a sedative for the client is not a correct action, as it may cause adverse effects such as confusion, falls, or respiratory depression. The nurse should avoid using sedatives unless absolutely necessary and use non-pharmacological interventions to calm the client.

Choice B reason: Removing the clock and calendar from the client's room is not a correct action, as it may worsen the client's disorientation and anxiety. The nurse should provide orientation cues such as a clock, a calendar, a radio, or a newspaper to help the client maintain a sense of time and reality.

Choice C reason: Providing distractions for the client during the day is a correct action, as it may reduce the client's boredom, agitation, and wandering behavior. The nurse should engage the client in meaningful activities such as music, games, crafts, or exercise that suit the client's interests and abilities.

Choice D reason: Raising all four side rails on the client's bed is not a correct action, as it may increase the risk of injury or entrapment if the client tries to climb over them. The nurse should use the least restrictive measures to prevent wandering, such as alarms, locks, or supervision.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice because this situation is the most urgent and requires immediate action. The charge nurse should prioritize the new admission and assign a staff nurse to receive the report and prepare the room for the client. The charge nurse should also ensure that the client's needs are met and that the admission process is smooth and efficient.

Choice B reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should plan the staffing for the shift and arrange for replacements or reassignments if necessary. The charge nurse should also communicate with the staff members who called in and document their reasons for absence.

Choice C reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should coordinate with the transport department and the occupational therapy department to reschedule the client's appointment or find an alternative way to transport the client. The charge nurse should also inform the client and the staff nurse about the change and apologize for any inconvenience.

Choice D reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should review the incident report and follow up with the nurse who wrote it and the client who was involved. The charge nurse should also implement corrective actions and preventive measures to avoid similar errors in the future.

A. Determine client care goals. B. Review the client's new laboratory values. C. Complete required tasks. D. Document assessment data.

Correct Answer is A

Explanation

Choice A reason: This is the first action the nurse preceptor should take to demonstrate appropriate time management. By determining the client care goals, the nurse preceptor can prioritize the most important and urgent tasks for each client and delegate appropriately.

Choice B reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Reviewing the client's new laboratory values is an important task, but it should be done after determining the client care goals and before completing the required tasks.

Choice C reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Completing the required tasks is an essential part of nursing care, but it should be done after determining the client care goals and reviewing the client's new laboratory values.

Choice D reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Documenting the assessment data is a vital part of nursing care, but it should be done after completing the required tasks and before the end of the shift.

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A nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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