The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?

Explain to the UAP that changes in a client's condition should be reported immediately.

Advise the UAP to stop providing care so the nurse can assess the client's condition. C

Ask the UAP to position the client so the oral medications can be administered.

Determine why the UAP did not notify the nurse of the change in the client's condition.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B)   Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C)   Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D)   Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

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Correct Answer is ["A","B","D"]

Explanation

A) Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B) Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C) Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D) Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E) Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

A. Place a bedside commode next to bed. B. Measure neurological vital signs every 4 hours. C. Suction oral cavity every 4 hours. D. Encourage family to participate in the client's care. E. Play classical music in room while client is

Correct Answer is ["A","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

Patient Data What other treatments might be helpful for this client? Select all that apply.

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?