Scenario
A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.
1500 hrs - Follow-Up Assessment
Based on the 1500 hrs assessment, categorize the following actions for the client.
Increasing IV fluid rate
Encouraging the client to sit up without assistance
Administering antiemetic medication
Monitoring respiratory rate closely
Providing reassurance and calming interventions
Checking electrolyte levels regularly
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
|
Action |
Essential |
Nonessential |
Contraindicated |
|
Increasing IV fluid rate |
|
The current rate is prescribed by the provider; increasing it without further assessment could lead to complications. |
|
|
Encouraging the client to sit up without assistance |
|
The client feels faint upon sitting up and is unsteady, so this could be dangerous. |
|
|
Administering antiemetic medication |
Helpful but not immediately critical. |
|
|
|
Monitoring respiratory rate closely |
Crucial due to client's rapid breathing and anxiety. |
|
|
|
Providing reassurance and calming interventions |
Important due to client's anxiety and discomfort. |
|
|
|
Checking electrolyte levels regularly |
Essential for ongoing monitoring given the client's symptoms. |
|
|
Essential
-
Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
-
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
-
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.
Nonessential
- Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.
Contraindicated
-
Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
-
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The glomerular filtration rate (GFR) does not recover during the oliguric phase of acute kidney injury (AKI). Recovery of GFR typically occurs during the recovery phase.
Choice B rationale
During the oliguric phase of AKI, urine output is typically less than 400 mL per 24 hours.
Choice C rationale
Renal function is not reestablished during the oliguric phase of AKI. This typically occurs during the recovery phase.
Choice D rationale
Blood urea nitrogen (BUN) and creatinine levels do not decrease during the oliguric phase of AKI. These levels typically increase due to decreased kidney function.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
A water heater temperature of 54.4°C (130°F) is a safety risk because it can cause burns. Older adults have thinner skin and are more susceptible to burns.
Choice B rationale
Electric cords behind furniture can be a safety risk because they can cause tripping or fire if the cords are damaged.
Choice C rationale
Throw rugs are a safety risk because they can slide underfoot and cause falls, especially in older adults who may have balance issues.
Choice D rationale
Raised toilet seats are not a safety risk. In fact, they are often recommended for older adults to prevent falls in the bathroom.
Choice E rationale
A bathtub with rails is not a safety risk. Rails can provide support and prevent falls when the older adult is entering or exiting the bathtub.
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