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.

Nursing Test Bank

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Correct Answer is B

Explanation

A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

A. Weigh the client and report any weight gain. B. Reporting any client complaints of pain or discomfort. C. Evaluate the client for sleep disturbances. D. Note and report the client's food and liquid intake during meals and snacks. E. Assess the client for weakness and fatigue.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct Answer is B

Explanation

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

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

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?

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)