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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A family attorney is the most appropriate professional to contact for more information about advance directives. Attorneys are knowledgeable about the legal aspects of advance directives, including living wills and durable power of attorney for healthcare, and can provide guidance on how to properly complete these documents.
B. A nurse manager may provide general information, but an attorney is more suited to address the legal aspects of advance directives.
C. A hospice nurse focuses on end-of-life care but may not have the expertise to provide comprehensive information about the legal requirements for advance directives.
D. A chaplain can offer spiritual support but is not the best resource for legal information regarding advance directives.

A. Elevate the area and apply light pressure over the site. B. Apply a cold pack to the area for twenty minutes. C. Document the site where the medication was given. D. Notify the healthcare provider of the allergic response.

Correct Answer is C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

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The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?

Correct Answer is A

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

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