A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits

The nurse should identify which of the following client's conditions can indicate the development of delirium.

Rationale:

• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.

• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.

• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.

• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.

• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.

• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.

Rationale:

A. 300 mg PO od: The dose is written clearly with no trailing zeros, and “od” (once daily) is acceptable though “daily” is preferred for clarity. This entry minimizes risk of misinterpretation and decimal errors.

B. 3.0 mg PO gd: Using a trailing zero (3.0 mg) increases the risk of a tenfold dosing error if the decimal point is missed. Also, “gd” is an incorrect abbreviation; “daily” or “once daily” should be used.

C. 10.000 units IV dally: Writing “10.000” with multiple trailing zeros is dangerous because the decimal point might be overlooked, causing a ten-thousand-fold error. Also, “dally” is a misspelling of “daily.”

D. 05 mL IM daily: Leading zeros before whole numbers (05 mL) are unnecessary and can cause confusion. The correct notation is “5 mL.” Leading zeros should only be used before decimals less than one (e.g., 0.5 mL).