What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Reduce environmental stimuli

Suction the oropharynx

Assess pulse oximetry

Administer oxygen

Answer and Explanation

The Correct Answer is A

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

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Correct Answer is D

Explanation

D. These effects are not the primary intended outcomes of the medication, but are known possible reactions that can occur in addition to the main therapeutic effect.

A. Synergistic effects refer to the combined action of two or more substances or medications that results in an effect greater than the sum of their individual effects.

B. Adverse effects are unintended and potentially harmful effects of a medication, even when the medication is used at therapeutic doses and in the correct manner.

C. Therapeutic effects are the desired and beneficial effects of a medication that contribute to treating or managing a medical condition. These effects are intended and typically guide the prescribing and administration of medications.

A. Place the patient in a negative pressure room. B. Use droplet precautions when the pathogen can be spread via sneezing, coughing or talking. C. Use droplet precautions to control the spread of infections that are transmitted person-to- person on air currents. D. An N-95 mask should be worn. E. Wear a surgical mask when working within 3 feet of the patient.

Correct Answer is ["B","E"]

Explanation

B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.

E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.

A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.

C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.

D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.

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What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that many medications given to clients have predictable, secondary effects which may be harmful or may be beneficial. The nurse always includes these effects in client teaching.

Correct Answer is D

Explanation

A nurse educator is teaching student nurses about droplet precautions. The educator emphasizes the differences between indications for droplet precautions versus airborne precautions. Which of the following statements about droplet precautions are correct? (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

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