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 B
Explanation
B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.
A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.
C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.
D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.
Correct Answer is B
Explanation
B. In a closed chest drainage system, slow and steady bubbling in the suction control chamber is typically an expected finding, as it indicates that the suction is active and functioning properly
A. Checking the tubing connections for leaks or the suction control outlet on the wall might be necessary if there were signs of a problem with the system's function.
C. Checking the suction control outlet on the wall is a reasonable action to ensure that the suction source is functioning appropriately and delivering the prescribed suction pressure to the chest drainage system. If there are any issues with the suction control outlet, they should be addressed to maintain proper suction.
D. Clamping the chest tube is not indicated based solely on the presence of slow, steady bubbling in the suction control chamber. Clamping the chest tube could obstruct drainage and lead to complications such as tension pneumothorax or retained hemothorax.
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