A client with dementia was admitted to a dementia unit after she began persistently wandering away from home. The nursing staff should plan to:
1. Provide unlimited freedom because the client has no place to go in the new neighborhood
2. Provide one-to-one supervision when the client is ambulatory
3. Place the client in a geriatric chair with a tray across the lap
4. Provide the client with an electronic alarm that sounds when the client nears the exit door
ANS: 4
Electronic alarms allow clients freedom of movement while still preventing them from wandering off the unit, as long as staff is attentive to the sound of the alarm. Option 1 has faulty rationale. Option 2 would be prohibitively expensive. Option 3 is inappropriate. It is a form of restraint used for staff convenience.
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What are the steps used when drawing medication from an ampule for use on the client?
Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Cover needle with its safety sheath or cap. Response 2. Snap neck of ampule quickly and firmly away from hands. Response 3. Tap the top of ampule lightly to move fluid from neck of ampule. Response 4. Hold ampule upside down to insert filter needle into center of ampule. Response 5. Draw up medication quickly using a filter needle. Response 6. Prepare the ampule.
The nurse is creating a plan of care for a patient in labor. Which nursing diagnosis would have priority for a patient receiving intravenous oxytocin (Pitocin)?
a. Risk for impaired comfort b. Risk for urinary retention c. Risk for nutrition, more than body requirements d. Risk for fluid volume excess
The client has just been told that his medical condition is terminal and that he has less than 6 months to live. The client begins to hyperventilate, and complains that he is light-headed and that his fingers, toes, and mouth are tingling
What action should be taken by the nurse? A) Prepare to resuscitate the client. B) Administer 25 mg of meperidine (Demerol) according to the p.r.n. pain order. C) Place the client in Trendelenburg position and ask him to cough forcefully. D) Have the client concentrate on slowing down respirations.
Clustering of data to ascertain a nursing diagnosis is accomplished through the use of
A) General systems theory process B) Problem-solving process C) Decision-making process D) Information-processing theory