How will a nurse deal with a client with toxoplasmosis and cytomegalovirus who is confused and is dislodging his I.V. access device; he is also supposed to receive amphotericin B (Amphotec) I.V?
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A. Place bilateral wrist restraints on the client. B. Ask the physician to order sedation for the client. C. Delay giving the drug until the client s confusion disappears. D. Tell a nursing assistant to stay with the client during the infusion.
Tell a nursing assistant to stay with the client during the infusion.-rationale: the client needs the medication to combat the protozoal infection. because he has been dislodging the i.v. access devices, a staff member should remain with him during the infusion. bilateral wrist restraints are a poor choice for managing this situation, and using them doesnt ensure that the client will receive the medication. giving sedation to a confused client is risky, and its a poor alternative to having a staff member remain with the client. administering the drug shouldnt be delayed; appropriate nursing action allows for the drugs administration.client needs category: physiological integrityclient needs subcategory: pharmacological and parenteral therapiescognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 681.