An older adult client of a long-term care facility is awake at 0330 and wandering down the hall in unbuttoned pajamas. Which intervention should the practical nurse (PN) implement?
Bring the client to sit in the nursing station.
Administer a nighttime sedative.
Direct the client to go back to bed.
Engage the client to determine current needs.
The Correct Answer is D
A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Gloves
Gloves are essential when entering the room because MRSA (Methicillin-resistant Staphylococcus aureus) is a pathogen that can be transmitted through direct contact with contaminated surfaces or secretions. Gloves protect both the client and the PN from the spread of the infection and should be worn when touching the patient or surfaces/items in the room.
B. N95 Mask
An N95 mask is not required for MRSA infections unless there are concerns about airborne transmission, which is not typical for MRSA. MRSA transmission is primarily through direct or indirect contact rather than airborne routes, so an N95 mask is not necessary in this scenario.
C. Gown
A gown is required when there is a risk of contamination from the environment or the patient, especially with MRSA infections. It helps to protect the PN’s clothing and skin from coming into contact with any infectious materials from the surgical site.
D. Surgical Mask
A surgical mask is appropriate for MRSA to protect against droplets and to prevent the spread of infection. It is particularly useful if there is a risk of droplets from the patient or if the PN is performing procedures that might generate droplets.
E. Goggles
Goggles are not required for MRSA unless there is a specific risk of splash or spray that could potentially expose the PN’s eyes to infectious materials. In the context of a surgical site infection, goggles are not a standard part of the PPE unless additional procedures are being performed that involve splashes
Correct Answer is ["0.6"]
Explanation
- Medication dose: 30 mg enoxaparin
- Medication concentration: 30 mg per 0.3 mL (prefilled syringe)
- Frequency: Every 12 hours
- Duration: 10 days
Calculation:
- Injections per day: Since the medication is given every 12 hours, the client will receive injections 2 times per day (24 hours / 12 hours/injection).
- Total medication per day: To find the total amount of enoxaparin needed per day, multiply the single injection dose by the number of injections:
Total enoxaparin/day = Dose per injection x Number of injections/day = 30 mg/injection x 2 injections/day = 60 mg/day
- Volume of medication per day: Now, we need to find the volume of solution needed to deliver the total daily dose (60 mg) based on the medication concentration (30 mg/0.3 mL). We can achieve this with a proportion:
Volume (mL) / Total dose (mg) = Concentration (mg/mL)
Volume (mL) = (Total dose (mg) x Concentration (mL/mg)) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = (60 mg x 0.3 mL/mg) / 30 mg/mL
Volume (mL) = 18 mL / 30 mL/mL
Simplifying:
Volume (mL) = 0.6 mL
Therefore, the practical nurse (PN) should administer 0.6 mL of enoxaparin each day.
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