A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?
Hold the client's evening dose of digoxin.
Increase the client's fluid intake.
Complete a neurological check.
Administer the prescribed PRN antihypertensive medication.
Administer the prescribed PRN antihypertensive medication.
The Correct Answer is C
A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
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Related Questions
Correct Answer is D
Explanation
A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
Correct Answer is B
Explanation
A. Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
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