The nurse is preparing to give an emergency sedative injection to an agitated client.
Which action by the nurse is inappropriate?
Placing a client in restraints without having a healthcare provider's order.
Administering the medication to a client behind a closed curtain.
Enlisting security personnel to assist with restraining the client.
Informing a client that the medication being administered is a sedative.
The Correct Answer is A
Placing a client in restraints without having a healthcare provider’s order.
It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.
Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.
Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.
Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.
In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”
Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.
Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.
Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.
Correct Answer is C
Explanation
The nurse should first discuss with the client her meaning of heroic measures.
This will help the nurse to understand the client’s wishes and preferences for her care.
Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.
Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.
Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.
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