A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Choice A Reason:

Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.

Choice B Reason:

Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.

Choice C Reason:

Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.

Choice D Reason:

Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.

Choice A Reason:

Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.

Choice B Reason:

Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.

Choice C Reason:

Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.

Choice D Reason:

Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.

Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function.