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. "It is okay to take laxatives every day to help you have a bowel movement." Frequent laxative use can lead to dependence and decreased bowel function over time. Instead, non-pharmacologic measures such as fiber intake, hydration, and physical activity should be encouraged first.
B."Do not ignore the urge to have a bowel movement even if you feel it is inconvenient." Ignoring the urge can lead to constipation as stool remains in the colon longer, resulting in increased water absorption and harder stools. Encouraging regular bowel habits helps maintain normal function.
C. "Do not take opiate medications as those can cause constipation." While opiates can cause constipation, this statement is too broad. Some individuals may require opioid therapy for pain management. Instead, the focus should be on preventing and managing opioid-induced constipation rather than avoiding these medications altogether.
D. "Be sure to eat at least 20 grams of fiber and drink at least 1,000mL per day." While increasing fiber intake is important, 20 grams may not be sufficient (the recommended daily fiber intake for older adults is about 25–30 grams). Additionally, 1,000 mL (1 liter) of fluid may be inadequate, as older adults should aim for at least 1,500–2,000 mL per day unless contraindicated.
Correct Answer is B
Explanation
A. A 32-year-old with menstrual cramps. Cold therapy can help relieve pain and reduce pelvic inflammation.
B. A 78-year-old with peripheral arterial disease. Cold therapy causes vasoconstriction, which can further reduce circulation in clients with PAD, increasing the risk of tissue damage.
C. A 44-year-old with a hematoma to the leg: Cold therapy is recommended for hematomas as it reduces swelling and bleeding.
D. A 69-year-old with a pulled muscle: Cold therapy reduces inflammation and numbs pain, making it beneficial for muscle injuries.
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