A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?
Place the client's valuables in the facility's safe.
Observe the client's level of mobility.
Administer prescribed medications.
Electronically enter the prescriptions from the provider.
The Correct Answer is B
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
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Related Questions
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
Correct Answer is D
Explanation
A. Constipation is not typically associated with TPN because the client is receiving nutrients intravenously rather than through the gastrointestinal tract.
B. Respiratory depression is not a direct complication of TPN administration.
C. Hypotension is not a common complication of TPN unless associated with fluid shifts or infection.
D. Electrolyte imbalance is a potential complication of TPN due to the high concentrations of glucose, electrolytes, and other nutrients. Rapid infusion, improper formulation, or abrupt discontinuation can lead to imbalances in sodium, potassium, calcium, magnesium, and phosphate. Frequent monitoring of laboratory values is essential to prevent metabolic complications.
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