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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable
A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.
B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.
C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.
Correct Answer is D
Explanation
D. Assessing the client is the nurse's first responsibility when a medication error is suspected. The nurse should promptly assess the client's condition to determine if any harm has occurred as a result of the error. This assessment includes vital signs, physical assessment, and evaluation of any signs or symptoms related to the medication error.
A. Documenting the medication error is important for accurate record-keeping and subsequent investigation. However, it should not be the nurse's first action. The priority should be to assess and address any potential harm to the client.
B. Calling the physician may be necessary depending on the severity of the error and the client's condition. However, it is not the first responsibility of the nurse in response to a suspected medication error. The nurse's primary concern should be the immediate assessment and management of the client's condition.
C. Notifying the supervisor or charge nurse is an important step to report the incident and seek guidance on next steps. Supervisors can assist in managing the situation, implementing corrective measures, and ensuring appropriate documentation and reporting procedures are followed. This is typically one of the first actions after ensuring the client's safety.
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