A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Provide a back rub at bedtime.

Leave the door to the client's room open slightly.

Apply wrist restraints to prevent wandering.

Administer a PRN sedative prescription.

Answer and Explanation

The Correct Answer is A

A. Provide a back rub at bedtime:

This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.

B. Leave the door to the client's room open slightly:

Leaving the door open may not prevent wandering and could potentially lead to safety issues.

C. Apply wrist restraints to prevent wandering:

Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.

D. Administer a PRN sedative prescription:

Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.

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Correct Answer is D

Explanation

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

A. Withdraw the medication into a syringe and label it with the client's name. B. Throw the vial into the trash in the presence of another nurse. C. Place the vial with the remainder of the medication into a locked drawer. D. Ask another nurse to witness the medication being discarded.

Correct Answer is D

Explanation

A. Withdraw the medication into a syringe and label it with the client's name:

This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.

B. Throw the vial into the trash in the presence of another nurse:

Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.

C. Place the vial with the remainder of the medication into a locked drawer:

While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.

D. Ask another nurse to witness the medication being discarded:

This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.

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A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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