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 B

Explanation

Choice A reason: While fitting for an N95 mask is important, it is not required for droplet precautions, which are appropriate for meningococcal infections.

Choice B reason: For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.

Choice C reason: It is the responsibility of the healthcare facility to ensure that all staff members who require it are fitted for particulate filter masks, but this does not apply to droplet precautions for meningococcal infections.

Choice D reason: Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.

A. Skin turgor. B. Weight. C. Blood pressure. D. Lung sounds.

Correct Answer is B

Explanation

Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.

Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.

Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.

Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.

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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

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

Exhibits Chart Reviewed For each statement, click to indicate whether the statement is true or false.

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