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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Carrots are a good source of vitamin A, but they do not provide sufficient calcium or vitamin D for bone health.
B. Low-fat yogurt is an excellent source of calcium and vitamin D, which are important for postmenopausal women at risk for osteoporosis due to hormonal changes.
C. Beets are nutritious but are not particularly relevant for improving bone health.
D. Mixed berries are a great source of antioxidants but do not provide the same bone-strengthening nutrients as low-fat yogurt.
Correct Answer is B
Explanation
A. Sodium intake with meals and snacks affects the blood pressure. While sodium can contribute to blood pressure increases, the primary reason for monitoring blood pressure in this case is to detect the kidney-related hypertension.
B. Elevated blood pressure must be anticipated and identified quickly. Blood pressure can increase significantly in acute glomerulonephritis due to fluid retention and kidney impairment. Frequent monitoring helps to identify and treat elevated blood pressure early, preventing complications.
C. Blood pressure fluctuations mean that the condition has become chronic. Acute glomerulonephritis typically causes fluctuating blood pressure, but this does not necessarily indicate chronic disease.
D. Hypotension leading to sudden shock can develop at any time. Hypotension is less common in acute glomerulonephritis compared to hypertension, making this response less accurate.
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