A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Observe the client for 1 hr after meals.

Obtain the client's vital signs every other day.

Weigh the client every 48 hr.

Allow the client to eat meals in their room.

Answer and Explanation

The Correct Answer is A

Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.

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Correct Answer is D

Explanation

A. Chart a summary of the data at the change of the shift - Documenting a summary of data at the change of shift is appropriate for communication among healthcare providers but should not be the first action. It's important to document all relevant admission data promptly and accurately.
B. Note whether the client has a living will - While documenting the client's living will status is important for their care, it's not the first action to take during admission documentation. Immediate assessment and documentation of essential data related to the client's condition and history take priority.
C. Document the client's vital signs obtained by assistive personnel - Documenting vital signs obtained by assistive personnel is appropriate, but it should not be the first action. The nurse should first conduct a comprehensive assessment and document all relevant admission data.
D. Begin charting with an evaluation of the data - This is the most appropriate action. The nurse should start by evaluating and documenting the admission data systematically and comprehensively. This includes the client's chief complaint, medical history, allergies, current medications, vital signs, physical assessment findings, and any other pertinent information. Starting with an evaluation ensures that all relevant data are captured and documented accurately.

A. Lubricate the catheter with water-soluble gel. B. Position the sterile drape leaving the perineum exposed. C. Cleanse the client's meatus with antiseptic solution. D. Attach a prefilled syringe to the catheter inflation hub. E. None F. None

Correct Answer is C

Explanation

Answer: C. Cleanse the client's meatus with antiseptic solution.

Rationale:

A. Lubricate the catheter with water-soluble gel:
While lubrication is an important step in the catheterization process, it is not the first action to take. Proper cleansing of the meatus is essential to minimize the risk of introducing bacteria into the urinary tract during the insertion of the catheter.

B. Position the sterile drape leaving the perineum exposed:
Setting up the sterile field is crucial, but the first priority should be to cleanse the meatus to prevent infection. The sterile drape should be positioned after ensuring the area is clean and before catheter insertion.

C. Cleanse the client's meatus with antiseptic solution:
This is the first action the nurse should take. Properly cleansing the meatus with antiseptic solution helps reduce the risk of urinary tract infections by eliminating bacteria from the area prior to catheter insertion. It is a critical step in maintaining aseptic technique during the procedure.

D. Attach a prefilled syringe to the catheter inflation hub:
Attaching the syringe for inflation is done after the catheter is inserted and positioned correctly. This action comes later in the procedure, once aseptic measures have been completed and the catheter is in place.

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A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Rationale:

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