A patient with Alzheimer's disease (AD) who is being admitted to a hospital rehab facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Ask the patient why the wandering episodes have occurred

Place the patient in a room close to the nurse's station

Reorient the patient several times daily

Have the family bring in familiar items

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking the patient why the wandering episodes have occurred might not be effective because patients with Alzheimer's disease often have memory and cognitive impairments that make it difficult for them to understand or articulate the reasons for their behavior. Additionally, it may not address the immediate safety concerns associated with wandering.
Choice B reason: Placing the patient in a room close to the nurse's station is a practical and effective measure to enhance patient safety. Proximity to the nurse's station allows for closer supervision and quicker response if the patient attempts to wander. This action helps prevent potential accidents and ensures that the patient receives timely interventions if needed. It is a proactive approach to managing the wandering behavior commonly seen in patients with Alzheimer's disease.
Choice C reason: Reorienting the patient several times daily is an important aspect of care for individuals with Alzheimer's disease, as it can help reduce confusion and anxiety. However, this alone may not be sufficient to prevent wandering. While reorientation is beneficial, the immediate safety of the patient requires additional measures, such as close supervision.
Choice D reason: Having the family bring in familiar items can provide comfort and a sense of security for the patient, which is important in managing Alzheimer's disease. Familiar objects may help reduce anxiety and agitation, but they do not directly address the safety concerns associated with wandering. This action should be part of a comprehensive care plan that includes measures to prevent wandering and ensure patient safety.

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Correct Answer is ["C","D","E","G"]

Explanation

Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.

A. Apply a clean, dry dressing over the VTE/DVT site. B. Monitor activated partial thromboplastin time (aPTT) results for warfarin dosing. C. Administer the warfarin dose at the same time each day. D. Instruct patient to take aspirin or NSAIDS as needed for pain. E. Advise the patient to use electric razors, not straight razors, when shaving. F. Monitor level of anticoagulation with warfarin with INR results.

Correct Answer is ["C","E","F"]

Explanation

Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.

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A patient with Alzheimer's disease (AD) who is being admitted to a hospital rehab facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?

Nursing Test Bank

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Correct Answer is ["C","D","E","G"]

Explanation

Correct Answer is ["C","E","F"]

Explanation

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