A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Assess the client's bilateral hand grasp strength.

Place a padded tongue blade at the client's bedside.

Check the client's bedside glucose level.

Administer flumazenil IV per facility policy to the client.

Answer and Explanation

The Correct Answer is A

A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.

B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.

C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.

D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.

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Correct Answer is B

Explanation

A. Wears an N95 mask when providing wound care: MRSA is transmitted via direct contact rather than airborne particles, so an N95 mask is unnecessary unless the client has a secondary airborne infection like tuberculosis. Standard contact precautions, including gloves and gowns, are sufficient to prevent transmission.

B. Wears clean gloves when caring for the client: MRSA requires contact precautions, which include wearing gloves when touching the client or contaminated surfaces. Gloves help prevent the spread of bacteria, particularly from wound drainage, body fluids, or contaminated equipment.

C. Remains 3 feet away from the client: MRSA does not require droplet precautions, which would necessitate maintaining a distance of 3 feet. Instead, direct skin-to-skin contact or contact with contaminated surfaces is the primary mode of transmission, requiring gloves and gowns rather than distance.

D. Disposes of isolation gown outside of the client's room: Isolation gowns should be removed inside the client’s room to prevent cross-contamination. Removing the gown before exiting the room reduces the risk of spreading MRSA to other areas and healthcare personnel.

A. Instructions on how to take metoprolol B. How to check blood glucose at home C. Check feet weekly on the same day each week. D. Perform 100 min of physical activity per week. E. Weight loss tips F. Manifestations of hyperglycemia and hypoglycaemia

Correct Answer is ["B","C","F"]

Explanation

How to check blood glucose at home: Since the client has a blood glucose level of 250 mg/dL, which is elevated, it is essential to teach the client how to monitor their blood glucose at home. Self-monitoring will help the client manage their diabetes effectively and recognize when to seek medical attention.
Check feet weekly on the same day each week: Given the presence of an open wound on the client's foot, it is important to emphasize proper foot care and regular inspection for any sores or changes. Checking feet weekly can help prevent complications such as infections or ulcers, especially in clients with diabetes.
Manifestations of hyperglycemia and hypoglycemia: Educating the client about the signs and symptoms of both hyperglycemia (e.g., increased thirst, frequent urination, fatigue) and hypoglycemia (e.g., shakiness, sweating, confusion) is crucial for safety. This knowledge empowers the client to take appropriate action when they experience these symptoms.

Instructions on how to take metoprolol: There is no indication in the provided information that the client is prescribed metoprolol. While teaching about medications is important, it should be based on the specific medications the client is taking.
Perform 100 min of physical activity per week: While physical activity is beneficial for overall health and can help manage diabetes, the emphasis should be on tailoring an exercise plan to the client's current health status and capabilities. A more individualized approach should be taken, and it may not be the priority at this stage due to the client's current condition.
Weight loss tips: While the client has reported recent weight loss, it is unclear whether this is intentional or a result of uncontrolled diabetes. Teaching weight loss tips may not be appropriate until the client’s diabetes is better managed and their nutritional needs are assessed more thoroughly.

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A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Nursing Test Bank

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A charge nurse is observing a newly licensed nurse care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA). Which of the following observations of the newly licensed nurse indicates an understanding of infection control precautions?

Correct Answer is B

Explanation

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Correct Answer is ["B","C","F"]

Explanation

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