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 {"dropdown-group-1":"B"}
Explanation
Choice A rationale: Maintaining personal malpractice insurance is important for individual protection but does not directly address preventing litigation related to client dissatisfaction.
Choice B rationale: Discussing how to handle complaints from clients and/or their families is an important objective to include in the orientation classes for staff nurses, because it can help prevent litigation by a dissatisfied client.
Choice C rationale: Completing an adverse occurrence or variance report is a necessary step after an error or incident has occurred, but it does not prevent litigation by itself.
Choice D rationale: Describing how to obtain legal services, while valuable, is a reactive rather than proactive approach to preventing litigation.
Correct Answer is D
Explanation
Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.
Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.
Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.
Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.
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