The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

Raise the four side rails on the bed.

Close the client's room door.

Orient the client to the surroundings.

Secure a bed alarm on the mattress.

Escort the client back to her room.

Answer and Explanation

Correct Answer : C,D,E

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

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Correct Answer is D

Explanation

A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.

A. Warn the colleague that their actions are unprofessional. B. Discuss the action at the next staff meeting. C. Communicate the observation to the charge nurse. D. File a detailed incident report with the specific facility.

Correct Answer is C

Explanation

A. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

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The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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