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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable
A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.
B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.
C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.
Correct Answer is ["A","D"]
Explanation
A. Overweight or obesity is a modifiable risk factor. It can be addressed through lifestyle changes such as diet modification, increased physical activity, and behavioral interventions aimed at weight loss.
D. Smoking is a modifiable risk factor. It is within an individual's control to quit smoking, which can significantly reduce the risk of various health problems, including cancer.
B. A history of prostate cancer is not a modifiable risk factor. Once a person has had prostate cancer, it cannot be changed through lifestyle modifications or interventions.
C. Being male is a non-modifiable risk factor for prostate cancer. Gender is determined biologically and cannot be changed.
E. Age is a non-modifiable risk factor. As individuals age, they are naturally at higher risk for certain health conditions, including prostate cancer. Age cannot be changed through interventions.
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