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During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Keep the client's television on with the volume low

Insert an indwelling urinary catheter to minimize interaction with the client

Consult the provider regarding administering a mild sedative on a schedule

Move the client to a room near the nurses' station

Answer and Explanation

The Correct Answer is D

Move the client to a room near the nurses' station.

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.

A. Check the client's blood type and crossmatch it against the provider's orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D. Verify the client and blood product information with another licensed nurse

Correct Answer is D

Explanation

Verify the client and blood product information with another licensed nurse.

Rationale:

A - This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B - This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C - This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D - This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.

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During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Nursing Test Bank

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