What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?
Reduce environmental stimuli
Suction the oropharynx
Assess pulse oximetry
Administer oxygen
The Correct Answer is A
A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.
B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.
C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.
D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["24"]
Explanation
For a client prescribed 2 grams of amoxicillin/clavulanic acid every 12 hours, and given that the medication is supplied in 500 mg capsules,
The client would need to take four capsules to meet the 2-gram requirement per dose. Since the medication is to be taken every 12 hours, this equates to two doses per day.
For a 3-day business trip, the client would need to take a total of 6 doses. Therefore, the client should take 24 capsules (4 capsules per dose multiplied by 6 doses) with them to ensure they have enough medication for the duration of their trip.
Correct Answer is B
Explanation
B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.
A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.
C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.
D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.
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