A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first?
Confirm schedule for delivery of supplies.
Coordinate interdisciplinary health care services.
Demonstrate how to perform the procedure.
Clarity the clients actual and perceived health needs
The Correct Answer is D
A. Confirm schedule for delivery of supplies: Ensuring supplies are delivered is important for continuity of care, but it does not address the client’s immediate needs or understanding of peritoneal dialysis. This can be arranged after assessing needs.
B. Coordinate interdisciplinary health care services: Collaboration with other healthcare providers is essential for comprehensive care, but initiating coordination should follow a thorough assessment of the client’s specific needs and goals.
C. Demonstrate how to perform the procedure: Teaching the procedure is a critical step, but effective teaching requires understanding the client’s current knowledge, abilities, and perceived needs first. Without this assessment, instruction may not be individualized or effective.
D. Clarify the client’s actual and perceived health needs: Assessing both objective and perceived needs establishes a foundation for individualized care planning, teaching, and coordination. This is the first action because it informs all subsequent interventions and ensures the client’s priorities are addressed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Constipation: Constipation is uncomfortable but usually not life-threatening. It can be addressed after more urgent or potentially serious issues are assessed.
B. Indigestion: Indigestion, especially in a client on a cardiac unit, may indicate angina or myocardial ischemia. Chest discomfort requires immediate assessment to prevent progression to a myocardial infarction, making it the highest priority.
C. Swollen ankles: Peripheral edema can indicate fluid retention or heart failure but is typically a chronic or slowly developing issue. While important to monitor, it is not immediately life-threatening.
D. Urinary frequency: Urinary frequency is generally a non-urgent concern unless associated with other symptoms like pain or signs of infection. It is a lower priority compared to potential cardiac issues.
Correct Answer is C
Explanation
A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry: Teaching and guiding a client on incentive spirometry is a nursing intervention that requires assessment, education, and evaluation. It cannot be delegated to assistive personnel.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort: Chest discomfort in a post-MI client is a high-priority, potentially life-threatening issue. Only a licensed nurse can assess, intervene, and notify the provider, so this task is not appropriate for delegation.
C. A client who had a stroke 2 days ago and needs help toileting: Assisting a client with toileting is a basic activity of daily living and falls within the scope of practice for assistive personnel. The nurse can delegate this task safely.
D. A client who has awoken following a bronchoscopy and requests a drink: Post-procedure assessment and evaluating readiness for oral intake requires nursing judgment to ensure airway safety. This cannot be delegated to assistive personnel.
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