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 A

Explanation

The correct answer is choice A, feeding. Aspiration is a serious risk for clients who have difficulty swallowing or have other conditions that increase the risk of food or liquid entering the airway. During feeding, the nurse should monitor the client closely for any signs of distress or difficulty swallowing. The nurse may need to modify the consistency or texture of the food or liquid or use assistive devices such as a straw or feeding tube to reduce the risk of aspiration. Additionally, the nurse may need to position the client upright and provide support as needed during feeding. While safety observations are important during all activities, feeding is the most critical activity for clients at high risk of aspiration.

Correct Answer is ["1.8"]

Explanation

First, let's convert 90 mcg to mg:

90 mcg = 0.09 mg

Next, we can use dimensional analysis to calculate the required mL: 0.09 mg Lanoxin x 1 mL/0.05 mg Lanoxin = 1.8 mL

Therefore, the nurse will give 1.8 mL of Lanoxin elixir.

Rounding to the nearest tenth, the answer is 1.8 mL.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

Correct Answer is A

Explanation

Exhibits The physician orders Lanoxin elixir 90 mcg PO every morning. Drug available: Lanoxin elixir 0.05 mg/mL How many mL will be given?

Correct Answer is ["1.8"]

Explanation

An obese client is visiting a medical clinic seeking advice on ways to eat healthy and lose weight. The nurse should recommend which of the following to be included in the client's diet?

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

When conducting a physical assessment of the extremities, which of the following assessments would be the most correct?

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

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

A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?