A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Keep the room brightly lit while providing care.

Minimize verbal interaction with the client.

Monitor for change in speech.

Avoid dropping side rails or abruptly closing the door.

Report any change in level of consciousness.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

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Correct Answer is A

Explanation

Choice A reason: The catheter tubing is the most likely reservoir for the infection as it can harbor bacteria and introduce them into the urinary tract when not managed properly.

Choice B reason: The client's bed is an unlikely reservoir for the infection as it does not have direct contact with the urinary system.

Choice C reason: The urinary meatus is part of the normal flora but is not the primary reservoir for the infection in this scenario.

Choice D reason: The client's bladder is the site of the infection, not the reservoir that introduced the bacteria.

A. Increase the wound VAC suction to eliminate the drainage. B. Consult the wound care specialist to evaluate the wound. C. Cleanse the wound and discontinue the VAC system. D. Reapply the VAC system after irrigating away drainage. E. Document the wound measurements with tunneling.

Correct Answer is B

Explanation

Choice A reason: Increasing the wound VAC suction may help with drainage but does not address the underlying issue that might require specialist evaluation.

Choice B reason: Consulting the wound care specialist to evaluate the wound ensures that the client receives expert assessment and appropriate recommendations for care.

Choice C reason: Cleansing the wound and discontinuing the VAC system is not an appropriate action without specialist input.

Choice D reason: Reapplying the VAC system after irrigating away drainage may be necessary, but it should be done based on the specialist’s recommendations.

Choice E reason: Documenting the wound measurements with tunneling is important for record-keeping but does not address the immediate issue of evaluating the wound.

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A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Correct Answer is A

Explanation

A client with a non-healing wound and excessive drainage is using a wound VAC system. The nurse notices increased drainage and signs of possible infection. What is the most appropriate nursing intervention?

Correct Answer is B

Explanation

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