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?
Advise the UAP to stop providing care so the nurse can assess the client's condition.
Determine why the UAP did not notify the nurse of the change in the client's condition.
Ask the UAP to position the client so the oral medications can be administered.
Explain to the UAP that changes in a client's condition should be reported immediately.
The Correct Answer is A
A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.
B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.
C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.
D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing data on the abdomen, bowel sounds, and surgical dressing is the priority during a transfer report. An exploratory laparotomy involves a large incision, making the assessment of evisceration or internal bleeding a critical safety requirement. Absent bowel sounds are an expected finding immediately following abdominal surgery due to anesthesia and bowel manipulation. The receiving nurse must know the initial state of the dressing to monitor for any new sanguineous drainage.
B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.
C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.
D.A history of vomiting prior to surgery is part of the preoperative record and should already be documented in the client's medical history. While relevant for fluid balance, the transfer report should focus on the post-surgical recovery phase and current status. The PACU nurse must prioritize the acute results of the procedure over historical data from three days ago. Current ondansetron administration is more relevant for managing active postoperative nausea.
Correct Answer is "{\"xRanges\":[24.75253686935637,42.04549690532573],\"yRanges\":[62.826215561361366,80.16865945855535]}"
Explanation
To measure blood pressure from the left thigh, the diaphragm of the stethoscope should be placed over the popliteal artery, which is located behind the knee. This placement allows you to auscultate the Korotkoff sounds accurately when measuring thigh blood pressure.
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