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
Explanation
Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.
Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.
Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.
Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42
Correct Answer is B
Explanation
Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.
Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.
Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.
Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.
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