A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Use a bed alarm

Move client to a double room.

Use chemical restraints at bedtime.

Encourage participation in activities that provide excessive stimulation.

Answer and Explanation

The Correct Answer is A

A. Use a bed alarm: Bed alarms provide a safe method to alert staff when a client at risk for wandering attempts to leave the bed. This intervention promotes client safety without restricting freedom of movement, making it appropriate for dementia care.

B. Move client to a double room: Placing the client in a double room may increase confusion and agitation due to environmental overstimulation. It does not directly prevent wandering and could compromise safety.

C. Use chemical restraints at bedtime: Chemical restraints should be avoided unless absolutely necessary for safety and prescribed by a provider. They pose significant risks, including sedation, falls, and further cognitive decline, and are not a first-line intervention.

D. Encourage participation in activities that provide excessive stimulation: Excessive stimulation can increase agitation and the likelihood of wandering in clients with dementia. Activities should be calming, structured, and tailored to the client’s abilities to promote engagement without increasing risk.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "You will need to increase your fluid intake to resolve this problem.": Increasing fluid intake does not prevent or reverse the red-orange discoloration caused by rifampin. While hydration is important for overall health and kidney function, it does not address this expected side effect.

B. "Your provider will prescribe a different medication regimen.": A change in medication is not necessary for red-orange discoloration, as it is a harmless, expected effect of rifampin. Altering the regimen without indication could compromise tuberculosis treatment efficacy.

C. "This finding may indicate possible medication toxicity.": Red-orange discoloration of bodily fluids is not a sign of toxicity. Rifampin normally causes this harmless color change, and toxicity would present with other symptoms such as hepatotoxicity or jaundice.

D. "This is an expected adverse effect of this medication.": Rifampin commonly causes harmless red-orange discoloration of urine, sweat, saliva, and tears. Educating the client that this is expected helps reduce anxiety and reinforces adherence to the prescribed treatment regimen.

A. "We can draw blood samples from the PICC for diagnostic tests.” B. "We will replace the PICC every month." C. "We will change the dressing daily” D. "We can measure your blood pressure in either arm”

Correct Answer is A

Explanation

A. "We can draw blood samples from the PICC for diagnostic tests.": A PICC line provides reliable central venous access, and blood samples can be safely drawn from it. Using the PICC for lab collection helps reduce the need for repeated peripheral venipuncture and preserves peripheral veins during chemotherapy treatment.

B. "We will replace the PICC every month.": PICC lines do not require routine monthly replacement. They are designed for long-term use and can remain in place for weeks to months as long as they remain functional and free of infection. Routine replacement would increase risk of complications without clinical benefit.

C. "We will change the dressing daily.": PICC dressings should not be changed daily unless they become soiled, loose, or wet. Standard care involves changing dressings every 7 days for transparent dressings or every 48 hours for gauze, which helps maintain sterility and reduces infection risk.

D. "We can measure your blood pressure in either arm.": Blood pressure should not be taken on the arm with a PICC due to the risk of catheter damage, displacement, or impaired blood flow. BP measurements should be taken on the opposite arm whenever possible to protect the integrity of the catheter.

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A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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