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Patient Data

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.

Notify the social worker the client is awake.

Explain all procedures

Increase the propofol infusion

Consider extubating the client

Have the client sign consent forms for procedures already performed

Assess the client's pain

Determine the client's decision-making ability

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

Answer and Explanation

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.

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Correct Answer is ["83"]

Explanation

Calculation:

Convert the total infusion time from hours to minutes.

Total time (min) = 2hours×60minutes/hour

= 120minutes.

Calculate the infusion rate in drops per minute (gtt/min).

Total volume: 500mL

Drop factor: 20gtt/mL

Total time: 120min

Rate(gtt/min) = (TotalVolume(mL) × DropFactor(gtt/mL))/ TotalTime(min)

= (500mL × 20gtt/mL)/ 120min

= 10,000/ 120

=83.333...gtt/min

Round the answer to the nearest whole number.

= 83gtt/min.

A. Tell the client that the medication's side effects will most likely dissipate over time. B. Inform the client that gradual tapering must be used to discontinue the medication. C. Remind the client that feeling better is the therapeutic effect of the medication. D. Tell the client to discuss the medication side effects with the healthcare provider (HCР).

Correct Answer is B

Explanation

A. Tell the client that the medication's side effects will most likely dissipate over time: While side effects may lessen with continued use, this response does not address the client’s intent to stop the medication safely.

B. Inform the client that gradual tapering must be used to discontinue the medication: Abrupt discontinuation of antidepressants can lead to withdrawal symptoms and risk of relapse. Educating the client about the need for a gradual taper ensures safe discontinuation and continuity of care.

C. Remind the client that feeling better is the therapeutic effect of the medication: Acknowledging the therapeutic benefit is important but does not provide guidance on safely stopping the medication or addressing the client’s concerns.

D. Tell the client to discuss the medication side effects with the healthcare provider (HCP): Encouraging communication with the HCP is appropriate, but the immediate priority is to inform the client that discontinuation must be gradual to prevent adverse effects.

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Patient Data 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

Correct Answer is ["83"]

Explanation

Correct Answer is B

Explanation

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Patient Data

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.