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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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Naxlex Comprehensive Predictor Exams

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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. Observe him as he demonstrates the self-injection technique to another diabetic adolescent. B. Review his glycosylated hemoglobin level 3 months after the teaching session. C. Have the adolescent list the procedural step for safe insulin administration. D. Ask the adolescent to describe his level of comfort with injecting himself with insulin.

Correct Answer is C

Explanation

A: Observing the adolescent demonstrate the technique to another person may be helpful, but it does not directly assess the adolescent’s own ability to perform the skill.

B: Reviewing glycosylated hemoglobin levels 3 months later will not assess the immediate effectiveness of the teaching or the adolescent’s ability to perform insulin injections.

C: Asking the adolescent to list the steps ensures that they can recall and understand the procedure, confirming that the teaching has been effective and that the adolescent is capable of performing insulin injections safely.

D: Asking about comfort level is important for emotional support but does not directly assess the technical competency required for insulin administration.

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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

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct Answer is C

Explanation

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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.