A nurse is admitting a client who reports having diarrhea for the past 72 hr. Which of the following actions is the nurse's priority?
Provide oral replacement solution.
Obtain a prescription for antidiarrheal medication.
Offer the client a sitz bath.
Collect a specimen of the client's stool.
The Correct Answer is A
Choice A rationale:
Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.
Choice B rationale:
Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.
Choice C rationale:
Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.
Choice D rationale:
Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Selecting a site at least 5 cm (2 in) away from the umbilicus is essential because the tissue around the navel is often tougher and has altered vascularity, which can lead to inconsistent medication absorption.
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Choice B rationale: Air bubbles in prefilled syringes, such as those used for enoxaparin, should not be expelled. The air bubble is designed to be injected last to seal the medication within the subcutaneous tissue and prevent leakage.
Choice C rationale: Aspiration is no longer recommended for subcutaneous injections. There are no large blood vessels in the subcutaneous layer, and aspiration increases the risk of tissue trauma, hematoma formation, and client discomfort.
Choice D rationale: Subcutaneous injections should be administered at a 45° to 90° angle, depending on the amount of subcutaneous fat available. A 15° angle is used specifically for intradermal injections, such as TB skin tests.
Correct Answer is B
Explanation
Choice A rationale:
Inquiring whether the client's family knows about their anxiety is not directly related to addressing the client's current anxiety. The focus should be on the client's feelings and needs rather than involving the family in this particular instance.
Choice B rationale:
This choice is the most appropriate response. Asking the client to share memories from their past redirects their attention from the current anxiety-provoking situation. Discussing positive memories can help alleviate anxiety and provide comfort to the client.
Choice C rationale:
Suggesting to talk later after caring for other clients dismisses the client's immediate need for support and comfort. It's essential to address the client's anxiety promptly rather than delaying the discussion.
Choice D rationale:
Asking the client why they are feeling anxious might put them on the spot and could potentially escalate their anxiety. Instead of prompting them to explain the cause of their anxiety, the nurse should focus on providing reassurance and distraction.
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