The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)
Raise the four side rails on the bed.
Close the client's room door.
Orient the client to the surroundings.
Secure a bed alarm on the mattress.
Escort the client back to her room.
Correct Answer : C,D,E
A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The Trendelenburg position is not appropriate for managing low oxygen saturation levels and may not address the underlying issue. This position is more commonly used for hypotension, not hypoxemia.
B. Documenting the reading is important for record-keeping but does not address the immediate concern of the client's low oxygen saturation levels.
C. Ensuring that the nasal cannula is securely placed in the nostrils is crucial for effective oxygen delivery. A loose or improperly positioned cannula can result in inadequate oxygenation, contributing to lower oxygen saturation readings.
D. While placing the pulse oximeter on the earlobe might provide a different reading, it is essential first to ensure that the current oxygen delivery system is functioning properly and the cannula is properly positioned.
Correct Answer is ["C","D","E"]
Explanation
A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.
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