A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?

Administer IV fluids as prescribed.

Place the client in a supine position.

Monitor for signs of infection.

Notify the provider about abnormal findings.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Administering IV fluids as prescribed can be essential for maintaining fluid balance, but it does not directly address abnormal vital signs unless they are linked to hypovolemia. The nurse should prioritize identifying the cause of the abnormalities first, and then proceed with interventions aimed at stabilization and correction.

Choice B rationale

Placing the client in a supine position can exacerbate certain conditions, such as respiratory distress or hypoxia. While position changes may be needed in specific cases, this is not a primary action for addressing abnormal vital signs unless positional changes are directly implicated.

Choice C rationale

Monitoring for signs of infection is an important ongoing care strategy, especially when abnormal findings suggest potential sepsis. However, it alone does not resolve immediate concerns with abnormal vital signs and must be paired with communication and treatment strategies.

Choice D rationale

Promptly notifying the provider about abnormal findings ensures that the client's condition is evaluated comprehensively. Providers can order additional assessments or interventions to address potential underlying issues, thereby preventing clinical deterioration.

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Correct Answer is A

Explanation

Choice A rationale

Alzheimer's disease affects cognitive function, making it difficult for clients to process and remember complex instructions. Limiting instructions to two steps at a time reduces cognitive overload and enhances the client's ability to follow directions. This approach is supported by evidence-based guidelines for managing Alzheimer's, which emphasize simplifying tasks to match the individual's functional capabilities.

Choice B rationale

Encouraging independence in activities of daily living (ADLs) may lead to frustration and increased agitation in clients with Alzheimer's. As cognitive decline progresses, the client often lacks the ability to independently complete ADLs, requiring structured assistance to prevent anxiety and promote safety.

Choice C rationale

Using socialization as a distractor during agitation is not effective because it may overstimulate the client, worsening the agitation. Alzheimer's clients are often sensitive to changes in environment and increased activity, necessitating calm and consistent approaches during episodes of distress.

Choice D rationale

Varying staff providing care disrupts consistency and routine, which are crucial for clients with Alzheimer's. Familiar caregivers help foster trust and reduce confusion, aligning with care practices that prioritize stability and minimize anxiety caused by frequent changes in personnel.

A. Tingling of the fingers. B. Serosanguineous drainage on the dressing. C. Report of sore throat. D. Soreness at the incision site.

Correct Answer is A

Explanation

Choice A rationale

Tingling indicates hypocalcemia due to parathyroid gland injury, a complication of thyroidectomy. Hypocalcemia arises when parathyroid hormone secretion decreases, impairing calcium homeostasis. Normal serum calcium ranges are 8.5–10.2 mg/dL.

Choice B rationale

Serosanguineous drainage is normal wound exudate consisting of serum and red blood cells. It reflects standard postoperative healing, provided there is no excessive volume or purulent drainage suggesting infection.

Choice C rationale

Sore throat is expected due to endotracheal intubation during anesthesia. Transient inflammation resolves spontaneously without clinical intervention.

Choice D rationale

Incisional soreness is typical and does not suggest complications. It results from tissue disruption during surgery and should subside as healing progresses.

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A nurse is assisting with the care of a client.The vital signs indicate abnormalities.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?