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. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

Correct Answer is []

Explanation

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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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

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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