A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.
Which of the following sources of information should the nurse rely on for accurate information about the client?
The client
Progress note
Medical history
Family information
The Correct Answer is A
A. The client:
The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.
B. Progress note:
Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.
C. Medical history:
The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.
D. Family information:
Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Auscultating lung sounds:
Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.
B. Obtaining the client’s temperature:
Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.
C. Assessing the strength of peripheral pulses:
Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.
D. Obtaining information about the client’s respirations:
Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.
E. Asking the client about a family history of any illness or disease:
Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.
Correct Answer is ["45"]
Explanation
To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:
mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL
Plugging in the values from the question, we get:
mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL
Simplifying the equation, we get:
mL to administer = 60 mEq x 15 mL / 20 mEq
mL to administer = 45 mL
Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.
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