After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?
Apply restraints to the patient's wrists.
Turn on the patient's bed alarm.
Administer a sedating medication.
Move the patient closer to the nurse's station.
The Correct Answer is D
A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.
B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.
C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.
D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Chicken noodle soup with Pedialyte and tea: Chicken noodle soup contains solids (noodles, vegetables, meat), which are not allowed on a clear liquid diet.
B. Chicken broth with Jell-O and coffee: Broth and Jell-O are transparent and fully liquid at room temperature, meeting clear liquid diet guidelines. As long as it is without milk or cream, coffee can be included in the diet.
C. Vegetable broth with yogurt and apple juice: Yogurt is not a clear liquid. Apple juice is okay if filtered, but yogurt makes the meal incorrect.
D. Tomato soup with a popsicle and water: Tomato soup is not clear, as it is opaque and pureed, which disqualifies it from the clear liquid diet.
Correct Answer is B
Explanation
A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.
B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.
C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.
D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.
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