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 A

Explanation

A. Negligence in nursing refers to the failure to provide care that meets established standards, resulting in harm to the patient. In this case, if the nurse failed to monitor vital signs as per hospital policies and this failure led to complications for the post-operative client, it could constitute negligence. Negligence involves breaching the duty of care owed to the patient, causing harm that could have been reasonably prevented.

B. Nonmaleficence is the principle of doing no harm. While it is an ethical principle guiding healthcare practice, it does not justify or excuse negligence. Negligence involves a failure to uphold the duty of care owed to the patient, resulting in harm due to substandard practice.

C. A misdemeanor typically refers to a lesser criminal offense. Negligence in healthcare generally does not rise to the level of a criminal offense like a misdemeanor unless there is gross negligence or willful misconduct. In most cases, negligence leading to harm is addressed through civil litigation rather than criminal charges.

D. While negligence can certainly be considered unethical behavior in the context of healthcare, negligence itself is a legal concept related to professional malpractice rather than solely an ethical breach. Ethical violations may involve different aspects of professional conduct not directly related to negligence, such as breaches of confidentiality or conflicts of interest.

A. Leave the new unit and return to the original unit B. Discuss the client's care with another nurse C. Say nothing and proceed to care for the client. D. Call the nursing supervisor to discuss the situation

Correct Answer is D

Explanation

D This action involves escalating the issue to a higher authority who can provide guidance and support. The nursing supervisor can assess the situation, provide advice on managing the critically ill client, and potentially reassign the nurse or provide additional resources.

A. This option does not address the immediate need to ensure the patient's safety and continuity of care. It's important to consider patient welfare and seek appropriate support before considering leaving the unit.

B. Discussing the client's care with another nurse could be a subsequent step, but it does not address the immediate need to ensure the nurse is qualified to provide the necessary care.

C. Proceeding without addressing the issue could jeopardize patient safety and is not ethically or professionally responsible. It's crucial to acknowledge limitations and seek appropriate assistance.

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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

A nurse fails to monitor vital signs in accordance with the policy's of the hospital for a post- operative client. As a result, complications occur. On what basis might a lawsuit be successful? The nurse:

Correct Answer is A

Explanation

The inexperienced nurse is reassigned to another unit to care for a critically ill client whose care is beyond her capability. What action should the nurse take first?

Correct Answer is D

Explanation

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

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