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HESI RN Med Surg 3 Questions

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Question 1 of 5

A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?

Correct Answer: C

Rationale: Confusion increases the risk of falls. Restraints are a last resort after non-pharmacological interventions, ensuring safety.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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