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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

The correct answer is choices B, C, and D.

When assessing respiratory rate, it is important to count for a full respiratory cycle, which includes both inhalation and exhalation. If the respiratory rate is regular, the nurse can count for 30 seconds and multiply by 2 to obtain the total number of breaths per minute. The nurse should also observe the depth and rhythm of the respirations, noting any abnormalities or changes. It is not recommended to pretend to take the radial pulse while assessing respiratory rate, as this can lead to inaccurate readings and is not a professional approach to care

A. stage I B. stage II C. stage III D. stage IV E. stage IV

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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 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 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?

The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

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

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

A 54-year-old man is participating in occupational therapy following a strokecausing right-sided weakness. What level of health promotion is being exhibited?

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.