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A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I'm sorry, but your sibling's medical information is none of your business.
- B. I can give you those results as soon as I get them back from the lab.
- C. I can only give medical information to the client with an approved interpreter.
- D. The healthcare provider will share this information with you.
Correct Answer: C
Rationale: Approved interpreter ensures confidentiality.
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When a home health nurse is administering a 10-day prescription for intermittent infusions of daptomycin to a client with Staphylococcus aureus cellulitis, the client inquires why the pharmacy delivered only a few of the premixed bags and not all of the doses. Which response should the nurse provide to the client?
- A. The medication is in short supply at the local pharmacy.
- B. The antibiotic has a limited shelf life after reconstitution.
- C. The healthcare provider should be notified of the discrepancy.
- D. The instructions may change over the course of therapy.
Correct Answer: B
Rationale: Daptomycin has short stability post-reconstitution.
History and Physical
A 75-year-old male presents to the emergency department (ED) with poorly controlled diabetes. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, insulin-dependent diabetes, and mobility issues. He requires the use of a walker for mobility..
Nurse’s Notes
17:35
The client is moved from the gurney to the medical bed and requires two people to assist. The nurse performs a functional assessment. The client reports neuropathy in bilateral hands and lower legs. His skin is moist. He reports the need to wear an incontinence brief due to occasional accidents of both urine and stool. He explains that it is difficult for him to move quickly enough when he feels the urge to use the bathroom. At home, where he lives alone, he reports spending most of his time in his recliner, though he can ambulate within the home and does so if needed. He feels like he slides in bed to move because repositioning is difficult. He is currently using a front-wheeled walker. He reports difficulty eating a full meal and has less than optimal PO intake. Contracting sounds are noted.
17:35
The perineal area is noted to have redness with no open sores. The client has blanchable redness noted on both heels bilaterally and on the coccyx
Lab Results
Laboratory Test
Result
Reference Range
Glucose 180 mg/dl (10 mmol/L) 74 to 106 mg/dl (4.1 to 5.9 mmol/L)
Flow Sheet
17:15
Vital Signs and Assessments:
• Temperature: 98.7°F (37°C)
• Heart rate: 94 beats/minute
• Respiratory rate: 18 breaths/minute
• Blood pressure: 138/88 mmHg
• Oxygen saturation: 95% on room air
• Pain: 3 on a 0 to 10 pain scale, baseline numbness and tingling in bilateral upper and lower extremities
• Braden score: 13
Orders
17:15
• Capillary blood glucose before meals and bedtime
The nurse reviews the client’s data.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Cleanse and dress wound, Ofload coccyx and other bony prominences, Contact adult protective services, Immediately begin a bowel training program
- B. Pressure Injury, Elder abuse, Altered nutrition, Bowel obstruction
- C. Wound status, Documentation of skin prevention measures, Incontinence episodes, Vital signs
Correct Answer:
Rationale: Choice A reason:
There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.
Choice B reason:
The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.
Choice C reason:
There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.
Choice D reason:
Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.
Choice E reason:
An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.
Condition F reason:
The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.
Condition G reason:
There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:
Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.
Condition I reason:
There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.
Parameter J reason:
Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.
Parameter K reason:
While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.
Parameter L reason:
Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.
Parameter M reason:
Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.
Parameter N reason:
Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Secure an allergy bracelet around the client's wrist.
- B. Notify the dietary department of the client's fruit allergy.
- C. Send a list of medication allergies to the pharmacy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: A
Rationale: Allergy bracelet prevents immediate exposure.