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 A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

A. Blood pressure. B. Respiratory rate. C. Temperature. D. Pulse rate.

Correct Answer is B

Explanation

If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.

Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.

Therefore, the nurse should obtain the respiratory rate first.

Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.

Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.

Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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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?