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A nurse is caring for a client with pneumonia who is in bilateral wrist restraints for removing multiple peripheral vascular access devices. Upon assessment, the client developed agitation and increased confusion. The nurse should take which priority action?
- A. Obtain vital signs
- B. Release restraints and provide range of motion
- C. Auscultate lung sounds
- D. Assess skin integrity under each restraint
Correct Answer: A
Rationale: Obtaining vital signs is the priority to assess for physiological causes of agitation and confusion, such as hypoxia or fever.
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The nurse is interviewing an older adult who reports a disturbed sleep pattern. The client states that he lies in bed tossing and turning and cannot fall asleep. The nurse should recommend that the client
- A. Stay in bed until he falls asleep but change positions more frequently.
- B. Take more naps earlier in the day that do not exceed one hour.
- C. Eat a meal high in carbohydrates to promote sleep.
- D. Reduce your time in bed if unable to fall asleep after 20 minutes.
Correct Answer: D
Rationale: Leaving bed after 20 minutes prevents associating bed with sleeplessness, a sleep hygiene principle. Staying in bed, napping, or high-carb meals disrupt sleep patterns.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.
The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?
- A. P: 109; R: 26; BP: 110/70 mmHg
- B. P: 90; R: 12; BP: 99/54 mmHg
- C. P: 100; R: 18; BP: 161/98 mmHg
- D. P: 88; R: 14; BP: 166/52 mmHg
Correct Answer: B
Rationale: BP 99/54 mmHg indicates hypotension, requiring immediate follow-up. Tachycardia/tachypnea, hypertension, and wide pulse pressure are concerning but less urgent.