A nurse in an emergency department is caring for a client.
Complete the following sentence by using the lists of options.
The nurse should first review the medications that may be causing the client's
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
The nurse should first review the medications that may be causing the client's confusion, as certain drugs can contribute to altered mental status and should be promptly identified and addressed. After identifying and managing the cause, the nurse should focus on using alternative methods to keep the client safe, ensuring both immediate and long-term patient safety, especially if medication adjustments are required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.
E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.
F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.
Correct Answer is C
Explanation
A. Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential
information.
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