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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

A. "My stoma size will stay the same, even after it has healed." B. "My stoma will drain liquid fluid continuously." C. "I will change my pouch system every 2 weeks." D. "I will ensure that my medications are enteric coated."

Correct Answer is B

Explanation

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

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A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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