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

Exhibits

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:
Elastic bandages can contain latex, which could potentially cause an allergic reaction. However, latex-free alternatives are available. The client should be advised to specifically look for latex-free bandages. This statement indicates a need for further teaching because using standard elastic bandages might expose the client to latex.

Choice B rationale:
Many dishwashing gloves are made from latex, but there are latex-free alternatives available. The client should be instructed to use latex-free gloves to avoid latex exposure. This statement indicates a need for further teaching as the client might choose latex gloves unintentionally.

Choice C rationale:
Most ink pens do not contain latex. Therefore, using ink pens is generally safe for individuals with latex allergies. This statement does not indicate a need for further teaching.

Choice D rationale:
Balloon latex is a common allergen, and exposure to latex balloons can trigger an allergic reaction in individuals with latex allergies. This statement indicates a need for further teaching because the client should avoid latex balloons and opt for latex-free alternatives to prevent allergic reactions.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}

Explanation

The condition that poses the greatest risk to the newborn is Meconium aspiration syndrome due to color of amniotic fluid.

Meconium aspiration syndrome is a serious condition that can occur when a newborn inhales a mixture of meconium (the first stool) and amniotic fluid into the lungs around the time of delivery. The dark brown-greenish color of the amniotic fluid indicates the presence of meconium, which increases the risk of this condition.

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Essential

Nonessential

Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

2100 hrs - Critical Incident Exhibits A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?

Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}

Explanation

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