A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Place the client's bed at the lowest height.

Request a prescription for a nightly sedative.

Assist the client with toileting at least once every 4 hours.

Turn off all lights in the client's room at night.

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.

Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.

Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.

Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.

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Correct Answer is A

Explanation

Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.

Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.

Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.

Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.

A. Administer prescribed corticosteroids. B. Slow the infusion rate and contact the provider. C. Lower the head of the bed to semi-Fowler's position. D. Change the infusion to lactated Ringer's and maintain the rate.

Correct Answer is B

Explanation

Choice A reason: Administering prescribed corticosteroids is not the appropriate action for dyspnea associated with fluid overload from IV infusion. Corticosteroids are typically used to manage inflammatory conditions and are not indicated for this scenario.

Choice B reason: Slowing the infusion rate is the correct action when signs of fluid overload are present, such as dyspnea and hypertension. This helps to prevent further fluid accumulation. Contacting the provider is essential for further evaluation and management, which may include adjusting the fluid regimen or prescribing diuretics to manage the fluid overload.

Choice C reason: Lowering the head of the bed to a semi-Fowler's position may provide temporary relief for dyspnea but does not address the underlying issue of fluid overload. It is a supportive measure but should be accompanied by other interventions to manage the client's condition.

Choice D reason: Changing the infusion to lactated Ringer's would not address the issue of fluid overload and could potentially exacerbate the situation if the rate is maintained. The type of IV fluid is less important than the volume and rate of administration in the case of fluid overload.

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A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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