A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Only use restraints if the client becomes violent.

Use seclusion to manage the client's behavior.

Attempt the use of less restrictive methods before using restraints.

Use restraints for the minimum amount of time necessary.

Ensure the restraint limits the client's movement as little as possible.

Answer and Explanation

Correct Answer : A,C,D,E

A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone.

B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed.

C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm.

D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines.

E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.

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Correct Answer is D

Explanation

A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.

B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.

C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.

D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.

A. Place the client in a side-lying position. B. Clean the client's mouth with foam swabs. C. Position an emesis basin under the client's chin. D. Place a towel under the client's head.

Correct Answer is A

Explanation

A. Place the client in a side-lying position: Positioning the client on their side is the priority because it helps maintain airway safety and prevents aspiration during oral care. This step must be done first before beginning the cleaning process.

B. Clean the client's mouth with foam swabs: Oral cleaning is important to reduce bacterial growth and maintain comfort, but it should only be performed after the client is positioned safely to avoid aspiration.

C. Position an emesis basin under the client's chin: The emesis basin helps catch secretions and cleaning solution, but this is a supportive measure that comes after ensuring the client’s airway protection through proper positioning.

D. Place a towel under the client's head: A towel provides comfort and helps keep linens dry, but it is a secondary measure. Airway protection through positioning always takes priority before comfort and cleanliness.

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Body System	Findings
Gastrointestinal	Client reports abdominal pain as a 9 on a pain scale of 0 to 10. Abdomen is distended and firm. Bowels sounds are distant and hypoactive.
Integumentary	Skin is warm and dry. Perianal skin is excoriated, and small ulceration is noted.
Fluid balance	Tenting of skin for 4 seconds is noted. Capillary refill is 2 seconds. Temperature 38.7° C (101.7° F) Mucous membranes are dry. Respiratory rate 20/min

A nurse is caring for a client who is disoriented and is continuously getting out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse plan to insert the needle?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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