During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Keep the client's television on with the volume low

Insert an indwelling urinary catheter to minimize interaction with the client.

Consult the provider regarding administering a mild sedative on a schedule.

Move the client to a room near the nurses' station

Answer and Explanation

The Correct Answer is D

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.

B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.

C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.

D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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Correct Answer is D

Explanation

A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.

B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.

C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.

D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.

A. Initiate continuous cardiac monitoring. B. Administer 40 mEq/L potassium chloride PO with orange juice. C. Provide a diet rich in legumes, nuts, and green vegetables. D. Monitor the client for tetany.

Correct Answer is A

Explanation

A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.

B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.

C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.

D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs.

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During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

8-year-old male admitted with cystic fibrosis reports: Shortness of breath Wheezing throughout lung fields Productive cough with thick sputum A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

Correct Answer is A

Explanation

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