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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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"C"}}

Explanation

Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.

A. Alert and oriented B. chest pain described as pressure and tightness that is unrelieved with rest C. Radial and pedal pulses 2+ D. Capillary refill 2 seconds E. Rapid and shallow breaths F. Clear breath sounds throughout bilateral lungs G. 7 on a 0 to 10 scale, tightness and pressure in chest

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

Explanation

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"C"}}

Explanation

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

Explanation

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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.