A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.
Complete the following sentence by selecting the most appropriate actions based on the client’s current status.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first: Response 1: Notify the primary health care provider immediately.
This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.
Then, the nurse should: Response 2: Start an IV line for potential medication administration.
Starting an IV line ensures that the client can receive any necessary medications quickly.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Verbal consent alone is not sufficient for invasive procedures like urinary catheter insertion. Documented consent is necessary to ensure legal and ethical compliance.
Choice B rationale
Having another nurse co-sign the consent does not verify the client's explicit agreement to the procedure. It is important that the client’s direct consent is documented.
Choice C rationale
Checking the medical record for a previous consent form may not reflect the client's current willingness. Consent should be obtained fresh to confirm current understanding and agreement.
Choice D rationale
Witnessing the client's signature on a consent form ensures that the client has been informed and agrees to the procedure, fulfilling both legal and ethical requirements.
Correct Answer is D
Explanation
Choice A rationale
Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.
Choice B rationale
Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.
Choice C rationale
Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.
Choice D rationale
Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.
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