A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)
Instruct the client on use of call light.
Apply an ambulation alarm to the client’s leg.
Apply restraints to the client PRN.
Raise the four side rails of the client’s bed.
Check on the client hourly
Correct Answer : A,B,D
A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.
C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.
E. Checking on the client hourly is a routine nursing practice but may not be sufficient if there is a notable change in mental status; continuous monitoring and appropriate interventions are essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While E. coli is a common cause of urinary tract infections and other gastrointestinal infections, it is not a typical pathogen associated with osteomyelitis.
B. This bacterium is the most common cause of acute osteomyelitis, especially the methicillin-resistant Staphylococcus aureus (MRSA) strain.
C. Pseudomonas is more commonly associated with infections in immunocompromised individuals or those with chronic diseases, but it is not a typical cause of acute osteomyelitis.
D. Group B Streptococcus is not a common cause of acute osteomyelitis.
Staphylococcus aureus, including MRSA, is more frequently implicated in bone infections.
Correct Answer is C
Explanation
A. This is a technique used for assessing the fundus and is not related to corneal reflexes.
B. This is used for general eye examination but does not specifically test corneal reflexes.
C. This tests the corneal reflex, where a blink response indicates the reflex is intact.
D. This is used for assessing corneal abrasions or ulcers but is not a method to test corneal reflexes.
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