An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free.
After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?
Administer a prescribed narcotic antagonist to reverse the effects of any analgesic accumulation
Notify the healthcare provider and request a prescription for restraints to minimize the client's danger to self.
Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative
Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.
The Correct Answer is C
The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.
Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.
Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.
Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.
Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Demonstrate how to administer medication via a feeding tube.The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
- Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
- Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety.
Option D is incorrect because the temperature is too high and can cause harm to the client.
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