A nurse is caring for a client who has dementia and wanders frequently. Which of the following actions should the nurse take?
Apply a motion sensor mat to the client's bed.
Move the overbed table away from the bed.
Raise all four side rails while the client is in bed.
Leave the television on in the client's room.
The Correct Answer is A
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
a) You should shower instead of taking a tub bath. This is correct because showering reduces the risk of infection and promotes wound healing.
b) You may take aspirin for mild pain. This is incorrect because aspirin can increase the risk of bleeding and interfere with clotting. The client should take acetaminophen or another nonsteroidal anti-inflammatory drug (NSAID) for pain relief.
c) You should avoid lifting objects that weigh more than 8 pounds. This is correct because lifting heavy objects can strain the surgical site and cause bleeding or herniation.
d) You might see blood in your urine after coughing. This is correct because coughing can increase the pressure in the bladder and cause blood to leak from the urethra. This is normal and should subside within a few days.
e) You may resume sexual intercourse after 2 weeks. This is incorrect because sexual intercourse can cause trauma to the prostate and urethra and delay healing. The client should wait at least 6 weeks before resuming sexual activity.
Correct Answer is D
Explanation
Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.
Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.
Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.
Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.
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