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: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.
Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.
Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.
Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.
Correct Answer is D
Explanation
Choice A rationale: Asking the PN to change the sterile dressing while the nurse is busy may compromise patient safety and is not a prudent approach.
Choice B rationale: Reviewing the PN's skill checklist is important, but it may not provide immediate confirmation of the PN's competency in performing sterile wound care.
Choice C rationale: Telling the PN that past experience does not indicate the ability to perform skills may be discouraging and may not directly address the immediate need for a sterile dressing change.
Choice D rationale: Watching the PN perform sterile wound care to validate her skill level is the most direct and immediate way to ensure competency and patient safety.
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