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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.

Choice A is not the answer because it is rude and unprofessional.

Choice B is not the answer because it does not address the issue of privacy and confidentiality.

Choice D is not the answer because it does not address the issue of privacy and confidentiality.

A. Review the chart for number of voids over the last 24 hours. B. Evaluate the client for urinary incontinence. C. Scan the client's bladder after voiding. D. Palpate the suprapubic region for distention.

Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

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The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

Nursing Test Bank

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The nurse is preparing to give an emergency sedative injection to an agitated client.
Which action by the nurse is inappropriate?