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Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Assess the client's pain

Increase the propofol infusion

Notify the social worker the client is awake.

Have the client sign consent forms for procedures already performed

Consider extubating the client

Determine the client's decision-making ability

Decrease the noise and light stimuli in the room as much as possible

Explain all procedures

Answer and Explanation

Correct Answer : A,F,G,H

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

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Correct Answer is D

Explanation

A: An adult nurse practitioner may assist with clinical care but is not typically responsible for coordinating the client’s overall care progression.

B: The neurology unit supervisor focuses on clinical operations and support for neurology staff, not the coordination of a single patient's care.

C: The risk management nurse is responsible for identifying and mitigating potential risks within the healthcare environment but does not focus on coordinating individual client care.

D: The nurse case manager is responsible for overseeing the entire care plan, facilitating communication between healthcare providers, and ensuring that the client receives the necessary resources and follow-up care.

A. Keep the room brightly lit while providing care. B. Monitor for change in speech. C. Report any change in level of consciousness. D. Minimize verbal interaction with the client. E. Avoid dropping side rails or abruptly closing the door.

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

Explanation

A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client.

B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status.

C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse.

D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication.

E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.

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Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is D

Explanation

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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

Explanation

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin- resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

Exhibits

The client has started to wake up more, opening her eyes without stimulation and looking around the room.

Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.