Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Offering the client a bedpan every three hours.

Keeping an emesis basin near the bedside.

Providing oral care every four hours.

Changing the bed linens frequently.

Answer and Explanation

The Correct Answer is D

This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.

Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.

Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.

Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.

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Correct Answer is B

Explanation

A client with expiratory wheezing after an albuterol treatment.

This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.

The client needs immediate intervention to improve airway patency and oxygenation.

Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.

The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.

Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.

The client can wait until the nurse has assessed the other clients.

Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.

The client needs a dose of atenolol, which is a beta

A. It is a legal record of accountability for protection of the client and the nurse. B. It supports confidentiality and privacy and should never. C. It provides continuous reference for all care providers to refer to. D. it provides a framework for clients rights and records if they are violated.

Correct Answer is A

Explanation

It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.

Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.

Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.

Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.

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Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has received report on four clients. What client should the nurse see first?

Correct Answer is B

Explanation

The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

Correct Answer is A

Explanation

A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?

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