After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?

Apply restraints to the patient's wrists.

Turn on the patient's bed alarm.

Administer a sedating medication.

Move the patient closer to the nurse's station.

Answer and Explanation

The Correct Answer is D

A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.

B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.

C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.

D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.

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Correct Answer is D

Explanation

A. Applying sterile gloves to assist with a procedure: This is part of surgical asepsis (sterile technique) rather than medical asepsis.
B. Inserting an indwelling urinary catheter: This requires sterile technique, not just medical asepsis.
C. Preparing injectable medications: Medication preparation requires aseptic (sterile) technique to prevent contamination.
D. Picking up soiled tissues off of the bedside table: Medical asepsis includes hand hygiene and proper handling of contaminated items to prevent the spread of infection.

A. "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask" B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?" C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it D. “Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."

Correct Answer is D

Explanation

While this provides technical information, the surgical mask part is incorrect; the nurse should wear an N95 respirator, not a surgical mask.

B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"

While this is a therapeutic communication technique, it does not directly answer the patient's question about airborne precautions.

C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it."

This statement provides disease information but does not explain why airborne isolation is necessary.

D. "Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."

This provides a concise and accurate explanation of airborne precautions in terms the patient can understand.

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After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

Correct Answer is D

Explanation

The nurse is providing care to a patient who has tested positive for tuberculosis. The patient is moved into an airborne isolation room and the patient asks. "Why do I need to be moved into this new room?" How should the nurse respond?

Correct Answer is D

Explanation

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