The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Correct Answer is C

Explanation

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

A. Engage the client in non-threatening conversations. B. Encourage the client's family to visit more often. C. Encourage the client to participate in group activities. D. Schedule a daily conference with the social worker.

Correct Answer is A

Explanation

A. Engage the client in non-threatening conversations: Establishing a therapeutic nurse–client relationship through simple, supportive communication helps reduce isolation, builds trust, and may encourage the client to begin expressing thoughts and feelings.

B. Encourage the client's family to visit more often: Family involvement can be beneficial, but it may not be effective if the client is withdrawn. Increasing visits without first fostering a supportive environment could overwhelm or further isolate the client.

C. Encourage the client to participate in group activities: Group activities promote social interaction but may feel intimidating or threatening for someone who has been withdrawn for weeks. Gradual re-engagement beginning with one-on-one communication is more appropriate.

D. Schedule a daily conference with the social worker: Involving the social worker can be helpful for comprehensive care planning, but this does not directly address the immediate nursing priority of engaging the client therapeutically and reducing withdrawal.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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