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 B

Explanation

A. The hospital pharmacist can provide valuable information about medication dosages and potential discrepancies, but the primary source for clarification about the prescribed treatment plan is the healthcare provider who issued the prescription.
B. The healthcare provider should be contacted first to clarify the dosage discrepancy. The provider can confirm whether the dosage is correct or if there was an error in the prescription. This ensures that any potential issues are addressed by the person responsible for the treatment plan.
C. A medication reference guide is useful for checking normal dosages, but it does not clarify if a specific prescription is appropriate for the client’s condition. The provider’s confirmation is necessary for resolving discrepancies.
D. The nursing unit charge nurse may be consulted for additional guidance but is not the primary resource for verifying or resolving prescription dosages.

A. Send a list of medication allergies to the pharmacy. B. Secure an allergy bracelet around the client's wrist. C. Notify the dietary department of the client's fruit allergy. D. Place a latex-free supply cart outside the client's room.

Correct Answer is B

Explanation

A. Sending a list of medication allergies to the pharmacy is important for preventing adverse drug reactions but is not the immediate priority upon admission.
B. Securing an allergy bracelet around the client's wrist is the first action to ensure that all healthcare providers are immediately aware of the client's allergies, which is crucial for preventing accidental exposure to allergens.
C. Notifying the dietary department is important to prevent allergic reactions from food, but addressing the most immediate concern ensuring the client’s allergies are known to all involved in their care is a higher priority.
D. Placing a latex-free supply cart outside the room is important for preventing latex exposure but is secondary to ensuring that the client’s allergies are clearly communicated through an allergy bracelet.

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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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