A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Move the client to a double room.

Use a bed alarm.

Encourage participation in activities that provide excessive stimulation.

Use chemical restraints at bedtime.

Answer and Explanation

The Correct Answer is B

Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.

Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.

Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.

Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.

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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. A client with type 1 diabetes mellitus who has taken a high dose of insulin B. A client who has type 2 diabetes and has not taken any medication C. An older adult client taking an antibiotic for an infection D. A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels

Correct Answer is A

Explanation

Choice A reason: A client with type 1 diabetes mellitus who has taken a high dose of insulin is at significant risk for hypoglycemia. In type 1 diabetes, the body does not produce insulin, so insulin therapy is essential for controlling blood glucose levels. However, if the dose of insulin is too high relative to the patient's dietary intake or physical activity level, it can lead to a rapid decrease in blood glucose levels, resulting in hypoglycemia. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (3.9 mmol/L) and can cause symptoms such as confusion, sweating, weakness, and in severe cases, seizures or loss of consciousness.

Choice B reason: A client with type 2 diabetes who has not taken any medication may have elevated blood glucose levels but is not typically at immediate risk for hypoglycemia unless they are taking medications that lower blood glucose. Type 2 diabetes is characterized by insulin resistance, and while medication can help manage it, skipping medication does not usually result in hypoglycemia unless other factors are at play.

Choice C reason: An older adult client taking an antibiotic for an infection is not generally at risk for hypoglycemia unless the antibiotic interacts with other medications that the client is taking for diabetes management. Antibiotics themselves do not typically cause hypoglycemia.

Choice D reason: A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels is not at direct risk for hypoglycemia from the statin medication. Metabolic syndrome is a cluster of conditions that increase the risk for heart disease, stroke, and type 2 diabetes. While statins are used to lower cholesterol levels, they do not have a direct impact on blood glucose levels that would lead to hypoglycemia.

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A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

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

The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia?

Correct Answer is A

Explanation

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