An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?
Discuss with the family about placing the client in a skilled care facility.
Determine if the client is manifesting other neurologic changes.
Request family members report when the client is left alone.
Apply a restraining device to prevent the client from self injury.
The Correct Answer is B
Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.
Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.
Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Directing the UAP to delay weighing the client might not address the underlying issue. Understanding the client's refusal is essential for appropriate interventions.
Choice B rationale: Documenting that the client refused daily weights is important for documentation purposes, but it doesn't address the issue or provide information on the client's fluid status.
Choice C rationale: Instructing the UAP to weigh the client using a bed scale is a good option, but understanding the client's concerns or reasons for refusal is important for effective communication and addressing potential issues.
Choice D rationale: Asking the client why he does not want to be weighed is essential for understanding and addressing the client's concerns. It allows the nurse to provide education, reassurance, or alternative solutions to ensure the client's cooperation with the prescribed care plan.
Correct Answer is C
Explanation
Choice A rationale: Recording that the nurse questioned the prescription and seeking guidance from the supervisor can be done after calling the healthcare provider back.
Choice B rationale: Notifying the medical chief of staff may be necessary, but the nurse should first call the healthcare provider back.
Choice C rationale: Calling the healthcare provider back to report the dosage discrepancy is important, because it will allow the healthcare provider to correct the mistake and give a safe prescription.
Choice D rationale: Refusing to administer the medication and writing an incident report is an appropriate action, but it should be done if the healthcare provider does not respond or insists on giving the wrong prescription.
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