An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?

Discuss with the family about placing the client in a skilled care facility.

Determine if the client is manifesting other neurologic changes.

Request family members report when the client is left alone.

Apply a restraining device to prevent the client from self injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.

Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.

Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.

Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.

Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica

A. Record that the nurse questioned the prescription, and ask the supervisor for guidance. B. Notify the medical chief of staff of the situation, and request a prescription for the client. C. Call the healthcare provider back, and report that the dosage prescribed is four times the normal dose. D. Refuse to administer the medication, and write an incident report describing the event.

Correct Answer is C

Explanation

Choice A rationale: Recording that the nurse questioned the prescription and seeking guidance from the supervisor can be done after calling the healthcare provider back.

Choice B rationale: Notifying the medical chief of staff may be necessary, but the nurse should first call the healthcare provider back.

Choice C rationale: Calling the healthcare provider back to report the dosage discrepancy is important, because it will allow the healthcare provider to correct the mistake and give a safe prescription.

Choice D rationale: Refusing to administer the medication and writing an incident report is an appropriate action, but it should be done if the healthcare provider does not respond or insists on giving the wrong prescription.

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Naxlex Comprehensive Predictor Exams

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

The nurse manager is encouraging the hospital nursing administrators to seek Magnet status for an acute care hospital. Which rationale should the nurse use to describe the greatest advantage of obtaining Magnet status?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

The charge nurse is providing instructions to an unlicensed assistive personnel (UAP) who will be assisting with the care of a client who has a hiatal hernia. Which instruction should the charge nurse provide the UAP?

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?