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A nurse in a medical-surgical unit is caring for a clent

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the

followed by the client .
Answer and Explanation

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

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level:  Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.


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Related Questions

Correct Answer is A

Explanation

Rationale:

A. Arrange for an ethics committee meeting to address the family's concerns: An ethics committee helps resolve conflicts between families and healthcare teams while respecting patient autonomy and legal directives. This step promotes ethical decision-making and interdisciplinary collaboration.

B. Support the family's decision and initiate life-sustaining measures: Providing treatments against the client’s documented wishes violates ethical and legal standards. Advance directives must be honored, even when family members disagree.

C. Complete an incident report: An incident report is used to document errors or adverse events, not ethical conflicts. This situation requires ethical consultation and communication, not a formal incident report.

D. Encourage the family to contact an attorney: While families may seek legal counsel, it is not the nurse’s role to suggest legal action. This may escalate the conflict unnecessarily and delay proper ethical resolution.

Correct Answer is B

Explanation

Rationale:

A. Report the incident to the nurse manager: While reporting the error is necessary for institutional accountability and improvement, it should not take priority over assessing the client's immediate physiological response to the error.

B. Measure the client's vital signs: The nurse's first priority after a medication error is to assess the client for any adverse effects. Vital signs provide essential information about the client's condition and guide further actions to ensure safety.

C. Fill out an incident report: An incident report is a key part of documenting medication errors but is done after the client's condition has been assessed and stabilized. It is for internal use and not part of the medical record.

D. Notify the provider: The provider must be informed promptly, especially if corrective treatment is needed. However, this step comes after assessing the client's status to provide relevant clinical information during the report.

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