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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

d. “May I sit with you for a while?"

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

A. Oﬀer the client a prescribed sleep medication. B. Reposition the client and provide a back rub. C. Administer an as needed (PRN) prescription for pain. D. Provide a cup of hot chocolate at bedtime.

Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

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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?

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Naxlex Comprehensive Predictor Exams

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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?