Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

The correct answer is: c. Leave the light on in the room at night.

Choice A: Replace the IV catheter with a smaller gauge

Replacing the IV catheter with a smaller gauge is not directly addressing the issue of the client’s confusion and agitation. While a smaller gauge might be less irritating, it does not solve the problem of the client picking at the IV site. The pinkness at the IV site suggests mild irritation or early signs of phlebitis, which can be managed by monitoring and ensuring proper securement and care of the IV site.

Choice B: Apply soft bilateral wrist restraints

Applying wrist restraints should be a last resort due to the potential for causing distress, agitation, and physical harm to the patient. Restraints can lead to negative outcomes such as decreased circulation, pressure ulcers, and increased agitation, especially in patients with dementia. It is generally recommended to use less restrictive measures first.

Choice C: Leave the light on in the room at night

Leaving the light on in the room at night (C) can help reduce confusion and agitation in dementia patients, a phenomenon known as sundowning. However, it does not address the immediate issue of the non-occlusive dressing and the pink IV insertion site.

Choice D: Redress the abdominal incision

Given the situation, the most appropriate intervention would be to redress the abdominal incision (D). This is because the dressing is no longer occlusive, which can increase the risk of infection. Ensuring the dressing is secure and clean is crucial for the patient's safety.

Choice C is correct because providing supplemental oxygen is the first action that the nurse should take for a client who has a suspected pulmonary embolus. A pulmonary embolus is a life-threatening condition that occurs when a blood clot travels to the lungs and blocks the blood flow, causing hypoxia and respiratory distress. The nurse should administer oxygen to improve the client's oxygenation and prevent further complications.

Choice A is incorrect because notifying the healthcare provider is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The nurse should notify the healthcare provider after providing supplemental oxygen and assessing the client's vital signs and symptoms.

Choice B is incorrect because preparing a continuous heparin infusion per protocol is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. Heparin is an anticoagulant that can prevent further clot formation and reduce the risk of recurrence, but it does not dissolve existing clots or improve oxygenation. The nurse should prepare a heparin infusion after obtaining a prescription from the healthcare provider and confirming the diagnosis with diagnostic tests.

Choice D is incorrect because bringing the emergency crash cart to the bedside is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The emergency crash cart contains equipment and medications that can be used in case of cardiac arrest or other emergencies, but it does not address the immediate need of oxygenation. The nurse should bring the emergency crash cart to the bedside after providing supplemental oxygen and assessing the client's condition.