A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?
Replace the IV catheter with a smaller gauge
Apply soft bilateral wrist restraints
Leave the light on in the room at night
Redress the abdominal incision
The Correct Answer is D
The correct answer is: c. Leave the light on in the room at night.
Choice A: Replace the IV catheter with a smaller gauge
Replacing the IV catheter with a smaller gauge is not directly addressing the issue of the client’s confusion and agitation. While a smaller gauge might be less irritating, it does not solve the problem of the client picking at the IV site. The pinkness at the IV site suggests mild irritation or early signs of phlebitis, which can be managed by monitoring and ensuring proper securement and care of the IV site.
Choice B: Apply soft bilateral wrist restraints
Applying wrist restraints should be a last resort due to the potential for causing distress, agitation, and physical harm to the patient. Restraints can lead to negative outcomes such as decreased circulation, pressure ulcers, and increased agitation, especially in patients with dementia. It is generally recommended to use less restrictive measures first.
Choice C: Leave the light on in the room at night
Leaving the light on in the room at night (C) can help reduce confusion and agitation in dementia patients, a phenomenon known as sundowning. However, it does not address the immediate issue of the non-occlusive dressing and the pink IV insertion site.
Choice D: Redress the abdominal incision
Given the situation, the most appropriate intervention would be to redress the abdominal incision (D). This is because the dressing is no longer occlusive, which can increase the risk of infection. Ensuring the dressing is secure and clean is crucial for the patient's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31.6"]
Explanation
The correct answer is : 31.6 mL
Let’s calculate this step by step:
Step 1: Convert 10 mg of teriparatide to mcg. We know that 1 mg = 1000 mcg. So, 10 mg = 10 × 1000 mcg = 10000 mcg.
Step 2: The medication is labeled as 760 mcg/2.4 ml. This means that 760 mcg of the medication is present in 2.4 mL.
Step 3: Now, we need to find out how many ml will contain 10000 mcg of the medication. We can set up a proportion to solve this:
(760 mcg / 2.4 ml) = (10000 mcg / x mL)
Step 4: Solving for x, we cross-multiply and divide:
x ml = (10000 mcg × 2.4 ml) ÷ 760 mcg
Step 5: Calculate the result:
x ml = 24000 mcg·ml ÷ 760 mcg = 31.57894736842105 mL
Step 6: If rounding is required, round to the nearest tenth:
x ml = 31.6 mL
So, the nurse should administer 31.6 mLof the medication.
Correct Answer is C
Explanation
Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.
Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.
Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today