On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Assess the client for pain.

Apply wrist restraints.

Determine the client's blood pressure.

Administer a mild sedative.

Answer and Explanation

The Correct Answer is A

A.   Assessing the client for pain is a crucial step because pain can cause disorientation and agitation, especially after surgery. Pain might be a reason for the client's behavior. Addressing pain effectively can help improve the client’s comfort and potentially reduce disorientation and risky behavior.
B.   Applying wrist restraints should be considered a last resort and only when other interventions are not effective or if there is an immediate danger to the client. Restraints can increase agitation and potentially lead to other complications.
C.   Determining the client's blood pressure can be important, especially if there are concerns about hypotension or other cardiovascular issues that might contribute to disorientation. However, it is usually more effective to first address potential pain or discomfort.
D.   Administering a sedative may be appropriate in cases of severe agitation or disorientation, but it should not be the first action. It is essential to first identify and address any underlying causes of the client’s behavior, such as pain, before resorting to pharmacological interventions.

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 B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

A. Apply a debriding agent. B. Apply steri-strips. C. Obtain a wound culture. D. Remove every other suture.

Correct Answer is C

Explanation

A. Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B. Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C. Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D. Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

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

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is C

Explanation

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vagina tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?