The nurse is preparing to give an emergency sedative injection to an agitated client.
Which action by the nurse is inappropriate?

Placing a client in restraints without having a healthcare provider's order.

Administering the medication to a client behind a closed curtain.

Enlisting security personnel to assist with restraining the client.

Informing a client that the medication being administered is a sedative.

Answer and Explanation

The Correct Answer is A

Placing a client in restraints without having a healthcare provider’s order.

It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.

Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.

Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.

Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.

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Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

A. Ask questions in a vague, nonspecific format. B. Get the most difficult questions over with first. C. Begin with questions that are less sensitive in nature. D. Share personal values to put the client at ease.

Correct Answer is C

Explanation

Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.

A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.

Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.

Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.

Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.

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The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

Nursing Test Bank

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The nurse is preparing to give an emergency sedative injection to an agitated client.
Which action by the nurse is inappropriate?