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 D
Explanation
Choice A: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.
Choice B: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.
Choice C: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.
Choice D: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.
Correct Answer is B
Explanation
Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
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