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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lansoprazole does not typically cause indigestion; it treats conditions like GERD by reducing stomach acid production. Indigestion as a side effect would indicate an abnormal reaction.
Choice B rationale
Lansoprazole is best taken before a meal to optimize its ability to suppress gastric acid secretion. Taking it after a meal may reduce its effectiveness.
Choice C rationale
Reporting diarrhea is essential as it may indicate a rare but serious adverse effect like Clostridioides difficile-associated diarrhea. Early reporting helps prevent complications.
Choice D rationale
Lansoprazole capsules should not be chewed as the medication is designed for delayed release. Chewing disrupts this mechanism, leading to reduced efficacy or increased side effects.
Correct Answer is C
Explanation
Choice A rationale
A 2-hour fasting period is insufficient for bronchoscopy preparation. Aspiration risk during sedation necessitates fasting for at least 6 to 8 hours before the procedure, depending on clinical guidelines, to ensure gastric contents do not enter the airway.
Choice B rationale
Resuming oral intake immediately after the procedure is unsafe. Clients must wait until the gag reflex returns, as sedation suppresses protective airway reflexes, significantly increasing aspiration risk if eating prematurely.
Choice C rationale
Frequent monitoring of vital signs is essential post-bronchoscopy, as complications like respiratory depression, bleeding, or pneumothorax can occur. Continuous assessment allows early detection and intervention, ensuring client safety during recovery.
Choice D rationale
Clients are typically positioned supine or semi-Fowler’s during bronchoscopy to optimize airway visualization. Placing the client on the left side is not a standard practice and may impede the procedural view for the practitioner.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.