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 "{\"xRanges\":[269.328125,299.328125],\"yRanges\":[161,191]}"
Explanation
Rhinorrhea refers to the drainage of a clear fluid from the nose. When caring for a client following a head injury, the nurse should observe for rhinorrhea specifically at the nose. This is because the fluid leaking from the nose could potentially be cerebrospinal fluid (CSF), indicating a possible skull fracture or other serious head injury.
Correct Answer is A
Explanation
A. An older adult female client with cancer whose children are trying to decide whether to change to palliative care measures or continue disease control. This situation involves complex decision-making and requires the expertise of an RN to provide emotional support, facilitate family discussions, and address ethical considerations, all of which fall within the RN’s scope of practice.
B. A young adult client experiencing fatigue from radiation treatments is stable and can typically be managed by a PN, who can help monitor and address routine symptoms.
C. A middle-aged male client with a benign tumor who is recovering from an excisional biopsy is stable and likely requires minimal nursing care, which a PN can handle.
D. An adult client in remission receiving iron injections is stable and requires routine nursing care, which a PN can provide effectively.
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