A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
Monitor for impending signs of shock.
Initiate enteric precaution procedures.
Reduce light, noise and temperature.
Encourage electrolyte supplements.
The Correct Answer is A
Choice A reason: This client has signs of dehydration and fluid volume deficit, which can lead to shock, a life-threatening condition that occurs when the body's organs are not receiving enough blood flow. The nurse should monitor the client's vital signs, urine output, skin color, and level of consciousness, and report any changes to the physician.
Choice B reason: Initiating enteric precaution procedures is important to prevent the spread of infection, as vomiting and diarrhea may be caused by a contagious pathogen. However, this is not the most important action for the nurse to implement, as it does not address the client's immediate risk of shock.
Choice C reason: Reducing light, noise and temperature may help the client feel more comfortable and reduce nausea, but it is not the most important action for the nurse to implement, as it does not address the client's fluid volume deficit and potential shock.
Choice D reason: Encouraging electrolyte supplements may help replenish the electrolytes lost through vomiting and diarrhea, but it is not the most important action for the nurse to implement, as it may not be enough to restore the fluid balance and prevent shock. The client may need intravenous fluids and medications to correct the dehydration and hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Demonstrating how to complete an adverse occurrence or variance report is important, but not the most important objective. This report is a tool for quality improvement and risk management, but it does not prevent litigation by itself. The nurse should also communicate effectively with the client and/or their family, and document the incident and the actions taken.
Choice B Reason: Discussing how to handle complaints from clients and/or their families is the most important objective, as it can help prevent or resolve conflicts, and avoid escalation to legal action. The nurse should listen empathetically, acknowledge the client's feelings and concerns, apologize if appropriate, explain the situation and the plan of care, and involve the supervisor or other resources if needed.
Choice C Reason: Describing how to obtain legal services if needed is relevant, but not the most important objective.
This objective implies that litigation is inevitable or expected, which may create a negative or defensive attitude in the staff nurses. The nurse should focus on preventing litigation by providing safe and quality care and building trust and rapport with the clients and/or their families.
Choice D Reason: Maintaining personal malpractice insurance is advisable, but not the most important objective. This objective may protect the nurse's personal assets in case of a lawsuit, but it does not prevent litigation from occurring. The nurse should follow the standards of practice and the policies and procedures of the organization, and document accurately and thoroughly.
Correct Answer is B
Explanation
Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.
Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.
Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.
Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.
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