During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client's upper and lower extremities. Which intervention is most important for the nurse to implement on admission?

Assess peripheral oxygen saturation.

Determine baseline neurologic status.

Schedule a sitter around the clock.

Administer an IV anxiolytic medication.

Answer and Explanation

The Correct Answer is B

A. Assess peripheral oxygen saturation: While evaluating oxygenation is important in altered mental status, it is not the priority after restraints have been applied. Oxygen saturation may contribute to confusion, but neurological assessment is more directly relevant.

B. Determine baseline neurologic status: Establishing a neurological baseline is crucial after a sudden change in consciousness and behavior. It helps monitor for further deterioration or improvement and guides decisions about restraint necessity and care interventions.

C. Schedule a sitter around the clock: A sitter may be needed, but this decision should be based on a full assessment of the client’s condition and risk factors. It is not the first priority immediately after application of restraints.

D. Administer an IV anxiolytic medication: Medication may be considered later if the behavior persists or worsens, but it must be based on assessment findings and provider orders. The initial focus should be on identifying the underlying cause of the behavioral change.

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Correct Answer is D

Explanation

A. Review the pain medications prescribed: Reviewing available medications is useful for planning, but it should follow a more direct exploration of the client's current discomfort and verbal input.

B. Administer PRN oral pain medication: Administering medication without the client reporting pain or confirming the need can be inappropriate, especially if the client denies discomfort. Further assessment is needed first.

C. Monitor the client's nonverbal behavior: Continued observation is important but passive. The nurse should actively seek clarification to determine if intervention is needed.

D. Ask the client what is causing the grimacing: This approach respects the client's autonomy and provides an opportunity to explore the cause of the discomfort. It helps clarify if the grimacing is due to pain or another issue, guiding appropriate next steps.

A. Call the pharmacy to see which medications should be taken. B. Notify the healthcare provider (HCP) a fever develops. C. Use movement techniques taught by the physical therapists. D. Verify that a follow up appointment has been scheduled.

Correct Answer is A

Explanation

A. Call the pharmacy to see which medications should be taken: This indicates a misunderstanding of discharge instructions. The healthcare provider or nurse should clearly explain prescribed medications. Pharmacies do not determine which medications a patient should take post-discharge.

B. Notify the healthcare provider (HCP) a fever develops: This is an appropriate response, as a fever may indicate postoperative infection and requires prompt medical evaluation.

C. Use movement techniques taught by the physical therapists: Following movement and mobility instructions helps prevent injury and supports recovery, showing the client understands rehabilitation guidance.

D. Verify that a follow-up appointment has been scheduled: Ensuring continuity of care through a scheduled follow-up visit is appropriate and indicates responsible post-discharge planning.

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Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is A

Explanation

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