The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale:
• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.
• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.
• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.
• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.
• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.
• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Chromosomal abnormalities: Amniocentesis involves analyzing amniotic fluid to detect genetic and chromosomal disorders such as Down syndrome, trisomy 18, and neural tube defects. It is typically performed between 15 and 20 weeks gestation for diagnostic accuracy during this stage of fetal development.
B. Placental circulation: Assessment of placental blood flow and circulation is usually done via Doppler ultrasound, not amniocentesis. Amniocentesis does not evaluate the vascular function or perfusion status of the placenta.
C. Rh incompatibility: While amniocentesis may reveal fetal anemia due to Rh sensitization in rare cases, it is not the primary test used for diagnosing Rh incompatibility. Blood antibody screening and Doppler assessment of the middle cerebral artery are preferred for Rh-related concerns.
D. Fetal breathing movements: Fetal breathing is assessed through a biophysical profile or real-time ultrasound, not via amniotic fluid sampling. Amniocentesis does not provide information about the fetus’s respiratory activity or movement patterns.
Correct Answer is A
Explanation
Rationale:
A. "We will keep the number for poison control stored in our phones.": Having the poison control number readily accessible is a key component of home safety for toddlers, who are at high risk for accidental ingestion. Prompt access supports rapid emergency response and guidance.
B. "We will make sure our hot water heater is set to 54° C (129° F)": This temperature setting is too high and increases the risk of scald burns. Water heaters should be set at or below 49° C (120° F) to reduce the chance of accidental burns during bathing or handwashing.
C. "We will make sure to turn pot handles towards the front of the stove.": Turning pot handles to the front makes them easier for a toddler to grab, increasing burn and injury risk. Handles should always be turned toward the back or center of the stove to keep them out of reach.
D. "We will store medications on a high surface that our child can't reach": High surfaces are not secure enough, as toddlers may climb. Medications should be stored in locked cabinets to ensure they are completely inaccessible to curious children.
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