Patient Data
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.
Notify the social worker the client is awake.
Explain all procedures
Increase the propofol infusion
Consider extubating the client
Correct Answer : B,F,G,H
A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.
B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.
C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.
D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.
E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.
F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.
G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.
H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Excessive aerobic exercise: Moderate aerobic exercise is generally protective for cardiovascular health. The client’s symptoms occurred during normal activity, and there is no indication that his exercise is excessive or harmful, so this is less of a concern.
B. Vegetarian diet: A vegetarian diet is usually associated with lower cardiovascular risk due to reduced saturated fat intake and higher consumption of fiber and antioxidants. This is unlikely to be a contributing risk factor in this client.
C. Family health history: Both parents had heart disease, and the father had diabetes, placing the client at increased genetic risk for cardiovascular disease. Exploring family history further helps identify inherited risk factors and guides preventive strategies.
D. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, hypertension is a known cardiovascular risk factor. Assessing the duration and management of prior hypertension is important to evaluate cumulative risk.
E. Sexual history: While sexual history may be relevant in some cardiovascular assessments (e.g., erectile dysfunction as a marker), it is not a primary risk factor for heart disease in this context and does not require immediate exploration.
Correct Answer is A
Explanation
A. Demonstrate to the PN how to position the client more effectively for the procedure: The nurse is responsible for ensuring correct positioning to optimize visualization and safety during a sigmoidoscopy. Providing guidance or demonstration supports safe practice and enhances the PN’s competence.
B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: While additional assistance may be helpful, it does not address whether the client is positioned correctly, which is the immediate priority for procedural safety and effectiveness.
C. Assume care of the client and assign the PN to the care of a different client: Reassigning responsibilities may delay the procedure and does not utilize the opportunity for the PN to learn proper technique. Collaboration and teaching are preferred.
D. Acknowledge that the PN has positioned the client safely and correctly: Simply acknowledging the position without verifying or guiding may result in suboptimal visualization or risk to the client. The nurse must ensure accuracy rather than assume correctness.
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