Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Administer ondansetron to the client for nausea.

Obtain a blood glucose level.

Implement seizure precautions for the client.

Obtain the client's weight

Answer and Explanation

The Correct Answer is C

Rationale:

A. Administer ondansetron to the client for nausea: Treating nausea is important for comfort, but it does not address the most urgent risk. Nausea is not immediately life-threatening compared with potential complications from medication overdose.

B. Obtain a blood glucose level: Checking blood glucose can provide useful information, but there is no indication of hypoglycemia or diabetes-related crisis in this scenario. It is not the priority action.

C. Implement seizure precautions for the client: The client has been doubling the bupropion dose, which significantly increases the risk of seizures, especially at doses above the prescribed maximum. Seizure precautions address an immediate life-threatening risk and should be the first intervention.

D. Obtain the client's weight: Monitoring weight is important for assessing nutritional status and the severity of depression, but it is not an immediate safety concern. Life-threatening risks, such as seizures, take priority.

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Correct Answer is C

Explanation

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.

A. Dietitian B. Physical therapy C. Case manager D. Social services

Correct Answer is B

Explanation

Rationale:

A. Dietitian: A dietitian focuses on nutritional needs, which may be beneficial if the client has dietary concerns, but this does not directly address mobility issues related to lower extremity weakness.

B. Physical therapy: Physical therapists specialize in improving strength, balance, and mobility. A referral will help the client develop exercises and strategies to enhance function and reduce fall risk.

C. Case manager: A case manager coordinates healthcare services, but they do not directly provide rehabilitation for weakness. They may be involved later to arrange additional resources after therapy needs are determined.

D. Social services: Social services assist with psychosocial needs, financial support, and community resources, but they are not the primary referral for addressing physical mobility limitations.

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Exhibits A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

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Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)