Exhibits
The client has started to wake up more, opening her eyes without stimulation and looking around the room.
Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.
Assess the client's pain
Increase the propofol infusion
Notify the social worker the client is awake.
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client's decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : A,F,G,H
A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Carrots are a good source of vitamin A, but they do not provide sufficient calcium or vitamin D for bone health.
B. Low-fat yogurt is an excellent source of calcium and vitamin D, which are important for postmenopausal women at risk for osteoporosis due to hormonal changes.
C. Beets are nutritious but are not particularly relevant for improving bone health.
D. Mixed berries are a great source of antioxidants but do not provide the same bone-strengthening nutrients as low-fat yogurt.
Correct Answer is ["A","B","C","D","E"]
Explanation
Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.
Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.
Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.
Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.
Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.
Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.
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