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 ["A","B","D"]
Explanation
A) Correct - Clear beef broth is appropriate for a postoperative full-liquid diet, as it is a clear liquid and meets the dietary restrictions.
B) Correct - Vegetable juice can be included in a postoperative full liquid diet, as long as it is free of solid particles.
C) Incorrect - Canned fruit cocktails may contain solid pieces of fruit, which are not suitable for a full-liquid diet.
D) Correct - Vanilla frozen yogurt is a suitable option for a postoperative full-liquid diet, as it is in a liquid state when consumed.
E) Incorrect - Creamy peanut butter is not appropriate for a full-liquid diet, as it is a solid food and does not meet the diet's requirements.
Correct Answer is C
Explanation
A) Incorrect- an audible voice when client is trying to communicate, indicates that the client has some air passing through the vocal cords, which may be due to a partially deflated cuff or a speaking valve. This is not a life-threatening situation, but the nurse should ensure that the cuff pressure is adequate and that the client is not experiencing any discomfort or aspiration risk.
B) Incorrect- This may indicate atelectasis, pneumonia, or pleural effusion in that lung area. The nurse should auscultate the client's lungs more thoroughly, monitor the client's oxygenation and ventilation parameters, and report the findings to the provider.
C) Correct- This finding suggests that the client may have a ventilator disconnect, a leak in the circuit, or a cuff leak, which can compromise the client's oxygenation and ventilation. The nurse should immediately check the ventilator connections and tubing, and assess the client's vital signs and oxygen saturation.
D) Incorrect- high-pressure alarm sounds when the client is coughing, which is a common occurrence in mechanically ventilated clients who have increased airway resistance due to secretions, bronchospasm, or coughing. The nurse should suction the client as needed, administer bronchodilators if prescribed, and ensure that the ventilator settings are appropriate for the client's condition.
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