A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Orient the client to their surroundings.

Close the client's room door.

Escort the client back to the room.

Raise the four side rails on the bed.

Secure a bed alarm on the mattress.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.

Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.

Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.

Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.

Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.

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Correct Answer is D

Explanation

The correct answer is choice D. Paper mask and gown.

Choice A rationale:

The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.

Choice B rationale:

Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.

Choice C rationale:

A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.

Choice D rationale:

The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.

A. Leave the dressing off until consulting with the healthcare provider. B. Replace the gauze with a transparent dressing. C. Increase the frequency of the dressing changes. D. Apply a hydrocolloid gel dressing.

Correct Answer is D

Explanation

Choice A reason: Leaving the dressing off is not advisable as it can expose the wound to potential infection and delay healing.

Choice B reason: A transparent dressing may not be the best choice for a stage 3 pressure injury with significant granulation tissue.

Choice C reason: Increasing the frequency of dressing changes without specific orders may not be necessary and could disrupt the healing process.

Choice D reason: A hydrocolloid gel dressing is appropriate for a stage 3 pressure injury as it maintains a moist environment, which is conducive to wound healing and granulation.

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A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is D

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is D

Explanation

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