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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["D","E","F"]

Explanation

Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.

Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.

Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.

Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.

Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.

Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.

Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["A","C","D"]

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

View Question and Answer

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

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

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

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?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?