A nurse is caring for a client.

Vital Signs.

1600: Nurses' Notes.

Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.

Respiratory rate 18/min.

Pulse oximetry 98% on room air.

1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.

Respiratory rate 26/min.

Pulse oximetry 92% on room air.

1600: Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout.

1630: Client reports itching on the chest and has urticaria over the chest and trunk.

Client states they are having difficulty swallowing and feel as if there is a lump in their throat.

Bilateral breath sounds with scattered wheezing heard throughout.

Vital Signs.

Nurses' Notes.

Medication Administration Record.

Cefaclor 500 mg PO q8h.

Select the 3 findings that require immediate follow-up.

Choice A rationale:

Encouraging family members to call the client is a valuable emotional and social support, but it may not be as effective in reducing social isolation for a client at the end of life. While communication with loved ones is important, it may not fully address the client's need for personal interaction.

Choice C rationale:

Instructing the client to join an online support group can be a useful intervention to reduce social isolation, especially in cases where physical interaction is limited. However, it may not be as effective for all clients, as comfort with technology and online groups can vary. Additionally, it should be one of several strategies used to address social isolation.

Choice D rationale:

Asking the client's friends to text the client is a positive gesture, but it may not be as effective as scheduling home visits with the client. Text messages may not provide the same level of personal interaction and emotional support that physical visits can offer.

Choice B rationale:

Scheduling home visits with the client is the most effective intervention to reduce social isolation in a client at the end of life. It allows for in-person interaction, emotional support, and the opportunity to address the client's physical and emotional needs directly. Face-to-face contact can significantly improve the client's sense of connectedness and reduce feelings of isolation.

Choice A rationale:
Quality of practice involves the nurse's competence in providing care to patients and ensuring that the care meets established standards. Violating the quality of practice standard would typically involve issues related to the quality and safety of care provided. In this scenario, the nurse's violation is related to accessing a client's medical record without being involved in their care, which is an ethical breach rather than a violation of the quality of practice standard.
Choice B rationale:
Code of ethics is the standard of professional performance that the nurse is violating. Accessing a client's medical record without being involved in their care is a violation of the ethical principles outlined in the Code of Ethics for Nurses. This action breaches patient confidentiality and privacy, which are fundamental ethical obligations for nurses.
Choice C rationale:
Collaboration involves working effectively with other healthcare professionals to provide optimal patient care. Violations of the collaboration standard would typically involve issues related to teamwork, communication, and interdisciplinary relationships. The scenario described does not pertain to collaboration but rather concerns ethical conduct.
Choice D rationale:
Evidence-based practice refers to the integration of current research evidence into clinical decision-making and patient care. Violations of evidence-based practice would involve not following the latest research and best practices in patient care. In this case, the nurse's violation is related to ethical principles and patient privacy rather than evidence-based practice.