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 C

Explanation

A. Asking an unlicensed assistive personnel (UAP) to stay with the client does not directly address the client's concern about being unable to make it to the bathroom.
B. Placing the bedpan within the client’s reach may help, but it is less comfortable and dignified than using a commode, which is a better option for an ambulatory client.
C. Obtaining a bedside commode for the client to use is the best intervention as it provides a practical solution that allows the client to relieve herself without the anxiety of having to walk a distance, thus preventing any accidents.
D. Notifying the healthcare provider of the client’s concerns is unnecessary as this situation can be effectively managed by nursing intervention.

A. Family attorney. B. Nurse manager. C. Hospice nurse. D. Chaplain.

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.

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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

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Correct Answer is A

Explanation

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