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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Determine pulse pressure: Pulse pressure may provide insight into cardiovascular status but does not directly address the immediate respiratory concern suggested by the use of accessory muscles.

B. Check for neck vein distention: Jugular vein distention could indicate cardiac dysfunction, but the priority should be to assess the client's oxygenation status when signs of respiratory effort are observed.

C. Auscultate heart sounds: While heart sounds may be part of a broader assessment, they do not provide immediate information about oxygenation or respiratory compromise.

D. Measure oxygen saturation: Accessory muscle use indicates increased work of breathing or possible respiratory distress. Measuring oxygen saturation is the most direct and immediate way to evaluate the client’s oxygenation status and guide urgent interventions.

A. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. B. Before changing assignments, determine which staff members have fitted particulate filter masks. C. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care. D. Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client.

Correct Answer is A

Explanation

A. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client: Meningococcal pneumonia requires droplet precautions, not airborne precautions. A standard surgical mask is appropriate for preventing transmission via respiratory droplets during close contact.

B. Before changing assignments, determine which staff members have fitted particulate filter masks: Fit-tested N95 respirators are required for airborne pathogens (e.g., tuberculosis), not droplet-based infections. This action is unnecessary for meningococcal pneumonia.

C. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care: A filter mask is not needed at all for droplet precautions. This step adds unnecessary complexity and misunderstanding of the required PPE.

D. Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client: A particulate respirator is not indicated for droplet precautions. This action would delay care unnecessarily and is not aligned with standard isolation protocols.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow- up action should the nurse take first?

Correct Answer is D

Explanation

An unlicensed assistive personnel (UAP) is assigned to feed a client with meningococcal pneumonia for whom droplet precautions have been implemented. The UAP requests a change in assignment, reporting they have not yet been fitted for a N95 respirator mask. Which action should the nurse take?

Correct Answer is A

Explanation

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Stephylococcus aureus (MRSA). The nurse plans interventions to prevent multiple reentries to the client's room. In which order should the nurse perform the interventions?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse. "I feel as if I'm already so alone." Which action should the nurse take first?

A client requests heat therapy for lower back pain. Which action should the nurse take?

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

47. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.