A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
A client who has orthostatic hypotension and is receiving IV fluids
A client who has Type 1 diabetes and uses an insulin pump
A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
A client who is receiving heparin and has an aPTT of 34 seconds
The Correct Answer is D
Choice A reason: This client does not need an interdisciplinary conference because their condition is not complex or chronic. The nurse can manage the client's care by monitoring their vital signs, fluid intake and output, and hydration status. The nurse can also educate the client on how to prevent orthostatic hypotension by changing positions slowly and wearing compression stockings.
Choice B reason: This client does not need an interdisciplinary conference because their condition is well-controlled and self-managed. The nurse can manage the client's care by checking their blood glucose levels, administering insulin as prescribed, and providing dietary and lifestyle education. The nurse can also collaborate with the diabetes educator or the endocrinologist if needed.
Choice C reason: Although this client is at risk for pressure ulcers, their albumin level is within the normal range, indicating adequate nutritional status. Low albumin levels are often associated with poor wound healing and increased risk of skin breakdown, but in this case, nutrition does not appear to be a concern. Preventive measures, such as regular repositioning, skin assessments, and pressure-relieving devices, can be implemented by nursing staff without requiring an interdisciplinary meeting.
Choice D reason: This client is the most appropriate candidate for an interdisciplinary conference. The activated partial thromboplastin time (aPTT) is a critical lab value for monitoring heparin therapy, and a level of 34 seconds is below the therapeutic range. A subtherapeutic aPTT increases the risk of clot formation, indicating that the heparin dose may need to be adjusted. An interdisciplinary team, including the physician, pharmacist, nurse, and laboratory personnel, should collaborate to ensure safe and effective anticoagulation management. This conference would allow for a discussion on dosage adjustments, potential medication interactions, and continued monitoring to prevent complications such as deep vein thrombosis or pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
Correct Answer is B
Explanation
Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.
Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.
Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.
Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.
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