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 {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Given her symptoms of persistent horrible thoughts and memories about the event, difficulty sleeping, and a noticeable change in mood, the nurse likely realizes that she has acute stress disorder related to traumatic stress exposure.

A. The rash is due to distended oil glands that will resolve in a few weeks. B. This rash is characteristic of a medication reaction. C. The healthcare provider is being notified about the rash. D. This is a common newborn rash that will resolve after several days.

Correct Answer is D

Explanation

The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.

The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.

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Naxlex Comprehensive Predictor Exams

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

Explanation

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

Correct Answer is D

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?