The nurse is caring for a patient who is confused and agitated. The patient continues to get out of bed without assistance and is at high risk for falls. The nurse is considering alternatives to implement prior to applying restraints.

Of the following, which would the nurse NOT consider in the plan of care as an alternative to restraints?

Give the patient something to do while in bed, such as a coloring book or puzzle.

Play music or video selections of the patient's choice.

Place all 4 side rails up to prevent the patient from getting out of bed and falling.

Reduce stimulation noise, and light to calm the patient.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.

When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.

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Correct Answer is D

Explanation

The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.

A. Droplet Precautions B. Contact Precautions C. Airborne Precautions D. Neutropenic Precautions

Correct Answer is B

Explanation

The correct answer is choice B: Contact Precautions. Clostridium difficile (C-diff) is a bacterium that can cause severe diarrhea and other gastrointestinal problems. It is highly contagious and spreads through contact with contaminated surfaces or objects. Therefore, it is necessary to apply Contact Precautions for patients with C-diff to prevent the transmission of the infection. Contact Precautions involve wearing gloves and gowns when entering the patient's room and disposing of contaminated items properly. Additionally, hand hygiene is critical to preventing the spread of C-diff.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

Correct Answer is D

Explanation

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

Correct Answer is B

Explanation

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

What is the rationale for using continuous positive air pressure (CPAP) to treat sleep apnea?

The nurse is caring for a client with moderate vision loss. Which intervention would be most appropriate for this client?

A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

A home care nurse is caring for a comatose patient who requires total care. A visitor stops by the house identifying as a family friend and inquires about the patient's condition and if there is anything they can do to help the family. How should the nurse respond to maintain HIPAA compliance?

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?