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?

Move the client to a double room.

Use a bed alarm.

Encourage participation in activities that provide excessive stimulation.

Use chemical restraints at bedtime.

Answer and Explanation

The Correct Answer is B

Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.

Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.

Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.

Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.

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Correct Answer is C

Explanation

Choice A reason: The statement that a DNR prescription means the client will only receive pain medication is incorrect. A DNR (Do Not Resuscitate) order does not affect the provision of treatments other than those required to resuscitate the patient if their heart stops or they stop breathing. Patients with a DNR can still receive all other medical treatments and interventions aimed at managing symptoms and improving quality of life, including pain management.

Choice B reason: A DNR prescription does not limit the current treatment regimen in terms of ongoing treatments for the patient's condition. The DNR order specifically refers to not performing CPR (cardiopulmonary resuscitation) if the patient's breathing or heart stops. All other aspects of the patient's care plan, including aggressive treatments, can continue if they align with the patient's wishes and medical advice.

Choice C reason: This is the correct statement. A DNR prescription allows the patient to continue with their current treatment regimen. It is a directive that applies only in the event of cardiac or respiratory arrest, indicating that CPR should not be performed. However, it does not preclude the patient from receiving other medical treatments or interventions.

Choice D reason: A DNR prescription does not inherently limit the ability to receive invasive procedures. The decision to pursue or avoid invasive procedures would be based on the patient's overall treatment goals, prognosis, and personal preferences, not solely on the presence of a DNR order.

A. Check the pulse distal to the graft. B. Keep the left forearm below the level of the heart. C. Collect blood specimens from the graft. D. Splint the left forearm to prevent damage to the graft.

Correct Answer is A

Explanation

Choice A reason: Checking the pulse distal to the graft is essential to ensure that the graft is patent and that there is adequate blood flow to the distal extremity. A palpable pulse indicates that the graft is functioning properly and not occluded. The absence of a pulse could signify a serious complication, such as thrombosis or stenosis, which requires immediate attention.

Choice B reason: Keeping the left forearm below the level of the heart is not recommended as it can increase venous pressure and swelling, potentially compromising graft function. The extremity should be kept at or above heart level to promote venous return and reduce the risk of edema.

Choice C reason: Collecting blood specimens from the graft is generally avoided to prevent damage to the graft. Blood draws can be performed from other sites to protect the integrity of the graft.

Choice D reason: Splinting the left forearm is not a standard postoperative care measure for an arteriovenous graft. While protecting the graft from injury is important, immobilization with a splint is not necessary and can impede mobility and circulation.

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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

A client who has a terminal illness asks the nurse, "If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?" Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

A nurse is planning care for a client who is postoperative following the insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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