A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
Discuss with the client his inappropriate behavior prior to seclusion.
Offer fluids every 2 hr.
Document the client’s behavior prior to being placed in seclusion.
Assess the client’s behavior once every hour.
The Correct Answer is C
The correct answer is choice C: Document the client’s behavior prior to being placed in seclusion.
Choice A rationale:
Discussing with the client his inappropriate behavior prior to seclusion is important, but it’s not the most appropriate action. The priority is to ensure the safety of the client and others, which can be achieved by documenting the client’s behavior prior to seclusion.
Choice B rationale:
Offering fluids every 2 hours is a good practice to keep the client hydrated, especially if they are agitated or physically active. However, this is not the most appropriate action in this context.
Choice C rationale:
Documenting the client’s behavior prior to being placed in seclusion is the most appropriate action. This documentation is crucial for legal and ethical reasons, and it helps in evaluating the effectiveness of the intervention.
Choice D rationale:
Assessing the client’s behavior once every hour is important to monitor the client’s condition and response to seclusion. However, this is not the most appropriate action in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomachs.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.
Correct Answer is D
Explanation
The correct answer is choice **D. Identify possible precipitating factors related to the infections**.
Choice D rationale:
As a charge nurse concerned about a recent increase in facility-acquired catheter infections, the first step should be to identify possible precipitating factors related to the infections. This involves conducting a thorough investigation to determine the root causes of the increased infection rates. By identifying the underlying factors, the nurse can then develop targeted interventions to address the specific issues and prevent further infections.
Choice A rationale:
While scheduling nursing staff training for infection control procedures is important, it should not be the first action taken. Before implementing training, it is crucial to identify the factors contributing to the increased infection rates to ensure that the training addresses the specific issues at hand.
Choice B rationale:
Meeting with providers to discuss measures to decrease the infections is a necessary step, but it should not be the first action. Providers need to be informed about the situation, but their input will be more valuable once the precipitating factors have been identified.
Choice C rationale:
Revising the current policy for catheter care may be necessary, but it should not be the first action. Policies should be based on evidence-based practices and tailored to address the specific issues identified through the investigation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.