A nurse received change-of-shift report at 0700 for four clients. Which of the following actions should the nurse perform first?
Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900.
Obtain a breakfast tray for a client who received a morning dose of insulin aspart.
Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400.
Replace a client's enteral nutrition feeding solution that has been hanging for 24 hr.
The Correct Answer is B
Rationale:
A. Restarting an infiltrated IV is important for antibiotic therapy, but the dose is not due until 0900, so it is not the immediate priority.
B. Insulin aspart is a rapid-acting insulin that peaks quickly. The client must eat promptly to prevent hypoglycemia, making this the highest priority.
C. Administering pain medication for rheumatoid arthritis is necessary, but this is not life-threatening and can be addressed after preventing hypoglycemia.
D. Replacing an enteral feeding solution that has been hanging for 24 hr is important for infection control, but it is not as urgent as preventing acute hypoglycemia.
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Related Questions
Correct Answer is B
Explanation
Rationale:
A. A health care surrogate (or durable power of attorney for health care) does not have to be the oldest child; the client chooses the person they trust most to make decisions.
B. Advance directives are flexible and can be altered or revoked by the client at any time, as long as the client is competent.
C. A living will outlines the client’s treatment preferences, but it does not designate who will speak for the client. That role belongs to a health care proxy/surrogate.
D. Signing advance directives does not remove the client’s right to make decisions. The client retains autonomy as long as they are capable of decision-making.
Correct Answer is A
Explanation
Rationale:
A. Alcohol-based hand sanitizer is not effective against C. difficile spores. Hands must be washed with soap and water to physically remove the spores, making this action unsafe and requiring intervention.
B. Wearing a mask when caring for a client who has varicella is appropriate for airborne precautions.
C. Closing the door of a client on airborne precautions helps contain infectious particles and is correct.
D. Removing cut flowers from the room of a client in a protective environment is appropriate to reduce the risk of infection.
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