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 C

Explanation

Choice A rationale

Occupational therapists focus on assisting clients with daily living activities and adapting their environment. While important in overall rehabilitation, they do not specialize in addressing swallowing difficulties caused by dysphagia.

Choice B rationale

Respiratory therapists specialize in pulmonary care and respiratory management, including administering oxygen therapy. They do not address swallowing disorders, as their scope centers on respiratory functions.

Choice C rationale

Speech therapists are experts in managing dysphagia. They evaluate and treat swallowing disorders, providing strategies to improve swallowing function and safety, including dietary adjustments and therapeutic exercises.

Choice D rationale

Physical therapists specialize in mobility and musculoskeletal rehabilitation. While valuable in stroke recovery, their focus does not include managing dysphagia or its associated risks.

A. Current medication prescriptions. B. Primary health problem. C. Scheduled times for dressing changes. D. Number of family members who have visited. E. Admission vital signs from a week ago.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Current medication prescriptions are essential for ensuring continuity of care. Accurate documentation prevents medication errors and allows the receiving unit to administer the right medications at the correct times and dosages. It ensures the client’s therapeutic regimen continues uninterrupted and facilitates the management of conditions during the transfer process.

Choice B rationale

The primary health problem outlines the central issue requiring intensive care. This information is vital for prioritizing interventions and forming a focused care plan. It ensures the receiving team understands the client’s critical health needs and can provide the appropriate monitoring and treatment promptly.

Choice C rationale

Scheduled times for dressing changes are not typically included in transfer documentation because they represent non-urgent routine tasks. Prioritization is given to critical information like the client’s current condition and medical orders to ensure safety during the transition to the intensive care unit.

Choice D rationale

The number of family members who have visited is irrelevant to the clinical transfer process. Documentation should focus solely on medical and therapeutic information critical to the client’s ongoing care and safety, ensuring efficient communication between healthcare providers.

Choice E rationale

Admission vital signs from a week ago do not reflect the client’s current condition and are not useful for guiding care. Transfer documentation should include recent and relevant clinical data to assist the receiving team in assessing and managing the client’s immediate needs.

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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

A nurse is caring for a client who has dysphagia following a stroke.The nurse should recommend a referral to which of the following members of the interdisciplinary team?

Correct Answer is C

Explanation

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Correct Answer is ["A","B"]

Explanation

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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?