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At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

An adult client who has a history of sleep apnea and needs help applying a continuous positive airway pressure (CPAP) before bedtime.

The parent of a child who reports the child cannot sleep because there is too much noise in the hallway.

An older adult client recently admitted from a long-term care facility who is exhibiting sundowning behaviors.

An older adult client who is anxious about an impending procedure and is worried about being unable to sleep.

Answer and Explanation

The Correct Answer is A

A.   Sleep apnea is a serious condition where the airway becomes blocked during sleep, which can lead to significant health issues, including heart problems and severe oxygen desaturation. The CPAP machine is crucial for managing sleep apnea by ensuring continuous airflow during sleep. If this client needs help applying the CPAP and does not get the assistance they need, they may experience severe complications from untreated sleep apnea.
B.   While noise in the hallway can certainly disrupt a child’s sleep and cause distress, it is not an immediate health crisis. It is important to address environmental concerns for comfort and sleep quality but this situation is less critical compared to the potential health risks associated with untreated sleep apnea.
C. Sundowning refers to increased confusion and agitation in the late afternoon or evening, which can be distressing and challenging to manage. While important, this issue is generally not as immediately life-threatening as problems related to sleep apnea or severe anxiety about a procedure.
D.   Anxiety about an upcoming procedure and difficulty sleeping are significant concerns, especially for emotional and mental well-being. However, while this client’s anxiety should be addressed to improve their comfort and preparation for the procedure, it does not present an immediate physical threat to health like the potential complications of untreated sleep apnea.

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Correct Answer is ["A","B","C"]

Explanation

A. Escorting the client back to their room is a direct and immediate intervention that ensures the client is safely returned to a controlled environment. This action helps prevent further wandering and reduces the risk of falls or accidents.
B. Securing a bed alarm is a preventive measure that helps alert staff if the client attempts to get out of bed. This can be particularly useful for clients who are confused or at risk of wandering. The alarm provides an early warning to intervene before the client leaves the bed, thereby enhancing their safety and reducing the risk of falls.
C. Orienting the client helps them become more aware of their environment and can reduce confusion. Providing verbal cues and reassuring the client about their location and time can be beneficial in calming them and helping them to recognize where they are.
D. Raising all four side rails can be considered a form of restraint and is generally not recommended unless absolutely necessary and with appropriate justification. It can lead to increased risk of injury if the client tries to climb over the rails or if there is an emergency.
E. Closing the client’s room door can be a safety measure to prevent them from wandering out into other areas of the facility. However, it is crucial to ensure that the client is not left feeling isolated or trapped.

A. Take an over-the-counter laxative every morning. B. Drink six to eight large glasses of water daily. C. Try using over-the-counter enemas when needed. D. Walk around the block or further every day.

Correct Answer is B

Explanation

A. While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B. Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C. Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D. Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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At 2000, the unlicensed assistive personnel (UAP) reports several client problems to the nurse who is working on a medical unit. Which client needs the most immediate follow-up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?