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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Inserting the catheter without applying suction is correct technique. Suction should only be applied while withdrawing the catheter to prevent mucosal trauma and hypoxia. Initiating suction during insertion can damage tracheal lining and cause bradycardia due to vagal stimulation. Allowing clean insertion without suction reduces injury risk and supports effective secretion removal on withdrawal with controlled suction time.
Choice B rationale: Waiting 2 minutes between suction passes is too long and may delay secretion clearance, risking hypoxia and secretion buildup. Best practice is to wait about 30 seconds to 1 minute or until the client recovers baseline oxygen saturation and heart rate. Prolonged intervals may lead to atelectasis or respiratory distress in patients with poor reserve, especially if suctioning is incomplete or secretions are copious.
Choice C rationale: Suctioning should be limited to 10–15 seconds per pass to reduce hypoxemia and bronchospasm risks. Applying suction for 15 seconds falls within the upper acceptable range, particularly if preoxygenation is done. Extended suction beyond this can decrease PaO₂ levels rapidly. Limiting the suction time ensures safer removal of secretions while minimizing trauma and preserving adequate oxygenation.
Choice D rationale: Encouraging the client to cough facilitates mobilization of secretions toward the upper airway, making suctioning more effective. Coughing also enhances airway clearance naturally and may reduce the number of required suction passes. It is a therapeutic action in tracheostomy care that supports pulmonary hygiene, helps prevent atelectasis, and can reduce the need for deep suctioning interventions.
Correct Answer is A
Explanation
This statement indicates that the client understands the need to avoid activities that can increase intraocular pressure, such as lifting heavy objects, bending over, coughing, or straining. An increase in intraocular pressure can cause complications such as bleeding, inflammation, or recurrent detachment of the retina.
Choice B is wrong because sewing is a near-vision activity that can cause eye strain and fatigue. The client should avoid near-vision activities for at least two weeks after surgery.
Choice C is wrong because jogging is a vigorous exercise that can cause jarring movements and increase blood pressure. The client should avoid vigorous exercise for at least six weeks after surgery.
Choice D is wrong because bending at the waist can increase intraocular pressure and compromise the healing of the retina. The client should avoid bending at the waist for at least two weeks after surgery.
The retina is the light-sensitive layer of tissue that lines the back of the eye.
It converts light into electrical signals that are sent to the brain through the optic nerve.
A detached retina occurs when the retina separates from its underlying tissue due to a tear, hole, or break in the retina.
This can cause vision loss or blindness if not treated promptly.
The most common treatment for a detached retina is a surgery called vitrectomy. It typically involves three main steps:
- The vitreous gel inside the eye must be removed.
- A gas bubble is injected into the eye to hold the retina against its underlying tissue while allowing it to heal.
- Laser or cryotherapy creates scar tissue that helps reattach the retina.
The recovery time after retinal detachment surgery varies depending on the type and extent of the detachment, the type of surgery, and the individual healing process of the client.
Some general guidelines to follow after retinal detachment surgery are:
- Rest your eyes for at least two weeks after the surgery.
- Wear sunglasses when outdoors, as bright light may cause discomfort and strain on the eye that has been operated upon.
- If your doctor recommends, use artificial tears every few hours to keep moisture in the eye and lubricate it correctly.
- Take your medicines as directed by your doctor.
- You may use ice on your eye to reduce swelling
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