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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.

B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.

C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.

D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.

A. "Let me teach you about antibiotics and their usage." B. "Let me talk to the provider and see what we can do." C. "Why do you think you need an antibiotic?" D. “I understand your frustration. You need an antibiotic.”

Correct Answer is A

Explanation

A. "Let me teach you about antibiotics and their usage." This response provides education about antibiotics, including why they are not effective against viral infections. It acknowledges the client’s frustration while promoting understanding.

B. "Let me talk to the provider and see what we can do." This response suggests that the nurse might override the provider’s decision or negotiate an unnecessary prescription, which is inappropriate.

C. "Why do you think you need an antibiotic?" While this question encourages the client to express their thoughts, it may come across as dismissive or challenging rather than supportive.

D. "I understand your frustration. You need an antibiotic." This statement is incorrect because it reinforces a misconception that antibiotics are needed for viral infections, which can contribute to antibiotic resistance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

Correct Answer is B

Explanation

A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

Correct Answer is A

Explanation

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