A nurse in an emergency department is caring for a client.
Complete the following sentence by using the lists of options.
The nurse should first review the medications that may be causing the client's
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
The nurse should first review the medications that may be causing the client's confusion, as certain drugs can contribute to altered mental status and should be promptly identified and addressed. After identifying and managing the cause, the nurse should focus on using alternative methods to keep the client safe, ensuring both immediate and long-term patient safety, especially if medication adjustments are required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.
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