An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?
Give PRN lorazepam (Ativan) and cancel the transfer.
Obtain an order for restraints as needed and transfer the patient.
Notify the health care provider and postpone the transfer.
Inform the receiving nurse and then transfer the patient.
The Correct Answer is C
C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.
A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.
B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.
D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
B Low dose dopamine is not a contraindication to epinephrine administration.
C A sinus tachycardia is not a contraindication to epinephrine administration
D Lack of urine output is not a contraindication to epinephrine administration
Correct Answer is ["A","B","C","D","E"]
Explanation
First, the nurse should open the airway using a jaw-thrust maneuver (C) to ensure it is not obstructed. Next, they should determine the effectiveness of ventilatory efforts (B), as breathing is critical and any compromise must be addressed immediately. Following this, establishing IV access (D) is important for fluid resuscitation and medication administration. The nurse should then perform a Glasgow Coma Scale assessment (E) to determine the level of consciousness and neurological function. Lastly, removing clothing for a thorough assessment (A) is essential, but only after the critical steps concerning airway, breathing, circulation, and disability have been addressed.
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