A nurse is caring for a client who is receiving 0.45% sodium chloride. Which of the following actions should the nurse take?

Choice A reason: Avoiding eye contact with a client experiencing auditory hallucinations may increase feelings of isolation or mistrust. Appropriate eye contact fosters therapeutic communication, conveying empathy and engagement. This action is not evidence-based for managing hallucinations, as it fails to address the client’s experience or build trust, making it inappropriate.
Choice B reason: Encouraging the client to lie down in a quiet room may reduce stimuli but does not directly address auditory hallucinations. This approach is more suitable for sensory overload or anxiety, not for engaging with or understanding the client’s hallucinations, which requires active communication to assess and manage symptoms effectively.
Choice C reason: Asking the client directly what they are hearing is a therapeutic approach that validates their experience and helps assess the nature and impact of hallucinations. This facilitates reality orientation, builds trust, and informs treatment, such as adjusting antipsychotics. It aligns with evidence-based care for schizophrenia, making it the correct action.
Choice D reason: Administering antianxiety medication immediately is not the first step for auditory hallucinations, which are primarily managed with antipsychotics. Without assessing the hallucinations’ content or severity, this action is premature and may not address the underlying psychotic symptoms, making it less appropriate than engaging the client directly.

Choice A reason: Saturated sanguinous drainage post-reinforcement signals excessive bleeding, potentially indicating hemorrhage or poor wound healing. Two hours postoperative, this suggests vascular injury or coagulopathy, requiring urgent provider notification to prevent hypovolemia, infection, or further complications in the surgical site.
Choice B reason: Oxygen saturation of 96% on 2 L/min nasal cannula is normal (95-100%), indicating stable respiratory status. This does not require reporting, as it reflects effective oxygenation post-surgery, with oxygen therapy appropriately supporting recovery without signs of respiratory distress.
Choice C reason: A pain level of 2/10 post-medication indicates effective pain control, not warranting immediate reporting. Postoperative pain management targets comfort (<4/10), and this level suggests successful analgesia, with no evidence of complications like nerve injury requiring provider intervention.
Choice D reason: Urine output of 50 mL/hr is normal (>30 mL/hr) post-catheter removal, indicating adequate renal perfusion. This does not require reporting, as it reflects normal kidney function and hydration status in the early postoperative period, absent other concerning symptoms.