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 B
Explanation
Rationale:
A. "I should be able to follow my normal routine after the staples are removed from my incision.” Normal activities should be resumed gradually; simply removing staples does not mean the incision and abdominal muscles have fully healed.
B. "I will ask my partner to perform household chores until my incision is healed." Delegating strenuous tasks supports proper healing and prevents strain on the incision site, reflecting appropriate understanding of postpartum activity restrictions.
C. "I will wait 4 to 6 weeks to perform kegel exercises." Kegel exercises can usually begin soon after delivery to strengthen pelvic floor muscles and are not delayed for several weeks unless specifically advised.
D. "I will maintain modified bed rest for the first 48 to 72 hours at home." While initial rest is important, prolonged bed rest can increase the risk of complications like blood clots. Gradual ambulation is encouraged to promote circulation and recovery.
Correct Answer is D
Explanation
Rationale:
A. Gown: The gown should be removed after the gloves because it may be contaminated but has less direct contact with infectious material. Removing it after gloves helps reduce the risk of spreading pathogens from the hands to the clothing or environment.
B. Mask: The mask is usually removed last to prevent inhalation of airborne or droplet contaminants during PPE removal. Premature removal may expose the nurse to infectious particles still present in the surrounding air.
C. Eyewear: Goggles or face shields should be removed after gloves to avoid contamination of the face during removal. Touching the eyewear with potentially contaminated gloves could transfer pathogens close to the eyes or face.
D. Gloves: Gloves are the most contaminated PPE item due to direct patient contact and should be removed first. This limits the risk of transferring pathogens from the gloves to other PPE or surfaces during the removal process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.