A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Encourage frequent visits from friends.

Keep the over-the-bed light on.

Apply restraints to the upper extremities.

Play serene, soothing music.

Answer and Explanation

The Correct Answer is D

A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.

B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.

C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.

D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.

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Correct Answer is C

Explanation

A. Ensure the door to the client's room remains open: The door should be kept closed to minimize exposure to radiation. Keeping the door open increases the risk of radiation exposure to others in the area.

B. Wear sterile gloves during patient care: Sterile gloves are not required for care during internal radiation therapy unless there is direct contact with bodily fluids or radioactive materials. Standard precautions are sufficient.

C. Wear a lead apron when providing client care: A lead apron is recommended for healthcare workers to protect themselves from radiation exposure during internal radiation therapy. The lead apron absorbs radiation and helps reduce the risk of harmful exposure.

D. Place a dosimeter on the client's gown: The dosimeter is typically worn by healthcare workers to measure radiation exposure, not the client. The client would not wear a dosimeter in this situation.

A. Gently squeeze the tubing to remove excess drainage. B. Raise the drainage system to the client's chest level. C. Clamp the tubing to check for air leaks. D. Empty the collection chamber.

Correct Answer is C

Explanation

A. Gently squeeze the tubing to remove excess drainage: Squeezing the tubing is not recommended as it could cause injury or increase pressure within the system. The nurse should not manipulate the tubing in this way, as it does not address the continuous bubbling.
B. Raise the drainage system to the client's chest level: The drainage system should always be below the level of the client's chest to promote proper drainage. Raising the system to chest level could disrupt the drainage process and cause complications.
C. Clamp the tubing to check for air leaks: Continuous bubbling in the water seal chamber may indicate an air leak in the system. The nurse should clamp the tubing temporarily to isolate the source of the leak and check for any external leaks or loose connections.
D. Empty the collection chamber: The collection chamber should only be emptied when it is full. Continuous bubbling in the water seal chamber is more likely an indication of an air leak. The nurse should first assess for leaks before considering emptying the chamber.

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A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?

Correct Answer is C

Explanation

A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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