On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Assess the client for pain.

Apply wrist restraints.

Determine the client's blood pressure.

Administer a mild sedative.

Answer and Explanation

The Correct Answer is A

A.   Assessing the client for pain is a crucial step because pain can cause disorientation and agitation, especially after surgery. Pain might be a reason for the client's behavior. Addressing pain effectively can help improve the client’s comfort and potentially reduce disorientation and risky behavior.
B.   Applying wrist restraints should be considered a last resort and only when other interventions are not effective or if there is an immediate danger to the client. Restraints can increase agitation and potentially lead to other complications.
C.   Determining the client's blood pressure can be important, especially if there are concerns about hypotension or other cardiovascular issues that might contribute to disorientation. However, it is usually more effective to first address potential pain or discomfort.
D.   Administering a sedative may be appropriate in cases of severe agitation or disorientation, but it should not be the first action. It is essential to first identify and address any underlying causes of the client’s behavior, such as pain, before resorting to pharmacological interventions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. Establish mental status baseline. B. Insert an indwelling urinary catheter. C. Check the accuracy of medication list. D. Obtain a capillary blood glucose level.

Correct Answer is D

Explanation

A. While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B. Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C. Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D. Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

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

Correct Answer is D

Explanation

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

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?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?