An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free.
After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?
Administer a prescribed narcotic antagonist to reverse the effects of any analgesic accumulation
Notify the healthcare provider and request a prescription for restraints to minimize the client's danger to self.
Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative
Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.
The Correct Answer is C
The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.
Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.
Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.
Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.
Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- While understanding the frequency that a problem occurs can provide context to its significance and potential impact, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency alone does not ensure that the evidence collected will be directly applicable to the current situation.
B) Incorrect- Personal values are subjective and may influence an individual's perspective, but they are not the primary consideration when gathering evidence for evidence-based decision- making. Evidence-based practice aims to rely on objective and scientifically validated information rather than personal values, which can vary greatly among individuals.
C) Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.
D) Incorrect- While past experiences can offer insights, they are not the most important consideration for evidence-based decision-making. Relying solely on past experiences may not account for new developments, changing guidelines, or unique aspects of the current situation that were not present in previous encounters.
Correct Answer is ["A","B","D"]
Explanation
A) Correct - Providing contact information for community resources is important as it ensures that parents have access to support and information beyond the hospital setting.
B) Correct - Offering information about pool safety is relevant, especially considering that the child experienced a submersion injury. This education can help prevent future accidents.
C) Incorrect - While discussing child neglect is important, it may not be the most appropriate time to bring up potential charges. The immediate focus should be on education and support.
D) Correct - Informing parents about when to follow up with the child's pediatrician ensures continuity of care and monitoring of the child's condition after discharge.
E) Incorrect - Instructions on how to access long-term home care may not be necessary if the child's condition does not warrant it. This option can be excluded based on the information provided.
F) Incorrect - Assessing the parent's coping skills is important, but it is not part of pre- discharge education. Education related to the child's condition and safety is more pertinent.
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