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 A
Explanation
Choice A rationale: The priority is to ensure the client's safety and comfort. If the client is restrained for bed linen change, alternative methods that don't involve wrist restraints should be considered. The nurse manager should advise the staff nurse to remove the restraints promptly.
Choice B rationale: Determining whether the client has a PRN prescription for an antianxiety agent is not the priority in this situation. The immediate concern is the use of restraints for a non-emergency purpose.
Choice C rationale: Contacting the healthcare provider to ensure a prescription for restraints was written may be needed, but the immediate concern is addressing the use of restraints for changing bed linens.
Choice D rationale: Closing the door to the room to avoid disturbing other clients is not the priority in this situation. The primary concern is the use of restraints for a non emergency purpose.
Correct Answer is B
Explanation
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.
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