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A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.
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For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
The nurse is assessing the client. Select the 4 findings that require immediate follow-up
- A. Hallucinations
- B. Heart rate
- C. Sleep pattern
- D. Skin turgor
- E. Hygiene
Correct Answer: A, B, D, E
Rationale: The correct answers are A, B, D, E. Hallucinations may indicate a serious mental health issue needing immediate attention. Heart rate abnormalities can signify cardiovascular problems. Skin turgor changes could indicate dehydration. Poor hygiene may suggest neglect or underlying health issues. Sleep pattern changes and personal grooming are important, but not typically requiring immediate follow-up.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial to ensure the child's comfort and facilitate recovery. Administering analgesics on a scheduled basis helps maintain a consistent level of pain relief and prevents breakthrough pain. This approach is especially important in the immediate postoperative period when pain levels are typically higher. Options A, C, and D are incorrect because applying a warm compress, giving cromolyn nebulized solution, and offering clear liquids are not primary interventions for postoperative pain management in this scenario. Option D specifically is not recommended as clear liquids are usually introduced gradually to prevent complications. Providing analgesics on a scheduled basis is the best course of action to address the child's immediate postoperative pain effectively.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4. Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.