In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

Engage the client in regularly scheduled activities during the day.

Offer the client frequent reassurance that he/she will be safe.

Arrange the client's environment so the client can move about freely.

Assign a UAP to provide the client with total personal care.

Answer and Explanation

The Correct Answer is C

Clients with early-stage Alzheimer's disease may experience impaired judgment and cognitive decline, which can increase their risk for injury. Arranging the client's environment in a way that allows them to move about freely helps promote their safety and reduces the risk of accidents or falls.

Engaging the client in regularly scheduled activities during the day is a beneficial intervention as it provides structure and stimulation for the client. However, it may not directly address the risk for injury related to impaired judgment.

Offering the client frequent reassurance that they will be safe is important to provide emotional support, but it may not be sufficient in preventing physical harm or addressing the specific nursing problem of risk for injury.

Assigning a UAP (Unlicensed Assistive Personnel) to provide the client with total personal care may be helpful in assisting with activities of daily living. However, it does not directly address the risk for injury related to impaired judgment, and the nurse should have a central role in coordinating and overseeing the client's care.

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Correct Answer is C

Explanation

Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.

Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.

Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.

Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.

Correct Answer is ["200"]

Explanation

To calculate the mL/hour for the erythromycin infusion, we first need to determine the infusion rate in mL/minute.

The infusion is to be completed over 30 minutes, which is equal to 0.5 hours. Next, we divide the total volume (100 mL) by the total time (0.5 hours) to get the infusion rate in mL/hour:

Infusion rate = Total volume / Total time

Infusion rate = 100 mL / 0.5 hours Infusion rate = 200 mL/hour

Therefore, the nurse should program the infusion pump to deliver the erythromycin infusion at a rate of 200 mL/hour.

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In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is C

Explanation

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (DW) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump?

Correct Answer is ["200"]

Explanation

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

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