A community health nurse is performing a home health admissions assessment with a client. The client reports being unable to obtain their prescriptions. Which of the following actions should the nurse take first?
Notify the client's family member regarding their inability to obtain prescriptions.
Call the local pharmacist on behalf of the client.
Assess the barriers to the client's ability to obtain prescriptions.
Initiate a referral to a social worker.
The Correct Answer is C
Rationale:
A. Notify the client’s family member regarding their inability to obtain prescriptions: Involving family members can be helpful later, but the nurse must first understand why the client cannot obtain medications before deciding whether family assistance is necessary.
B. Call the local pharmacist on behalf of the client: Contacting the pharmacist may help resolve access issues such as refills or delivery, but this step is premature without identifying the specific barriers that prevent the client from getting medications.
C. Assess the barriers to the client’s ability to obtain prescriptions: The first action is assessment to determine the root cause of the problem. Barriers may include lack of transportation, financial hardship, limited mobility, or misunderstanding of the prescription process. Once the cause is identified, appropriate interventions or referrals can be made.
D. Initiate a referral to a social worker: A social worker can assist with financial or community resources, but the nurse should first gather assessment data to provide accurate information for an effective referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Inspection: Visual examination of the abdomen is the first step, allowing the nurse to observe contour, skin changes, and symmetry without disturbing underlying structures.
B. Auscultation: Listening for bowel and vascular sounds is performed after inspection and before palpation or percussion to avoid artificially altering bowel activity.
C. Palpation: Palpation is the final step in an abdominal assessment because pressing on the abdomen can alter bowel sounds or cause discomfort. It is performed last to prevent interference with earlier assessment steps.
D. Percussion: Percussion provides information about organ size, fluid, and gas presence and is performed after auscultation but before palpation to avoid disturbing bowel sounds.
Correct Answer is A
Explanation
Rationale:
A. 0.45% sodium chloride: This is a hypotonic solution that helps lower elevated serum sodium levels by promoting water movement into the intracellular space. It is appropriate for correcting hypernatremia gradually while preventing cerebral edema.
B. Lactated Ringer's: Lactated Ringer’s is an isotonic solution containing sodium, potassium, and calcium. It is not ideal for hypernatremia because its sodium content can maintain or worsen elevated serum sodium levels.
C. 0.9% sodium chloride: Normal saline is isotonic and contains a high concentration of sodium, which would not reduce hypernatremia and could exacerbate the condition if used for correction.
D. 3% sodium chloride: This hypertonic solution increases serum sodium levels and is used to treat hyponatremia, not hypernatremia. Administering it to a client with hypernatremia would worsen the electrolyte imbalance.
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