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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
When leaving a client's isolation room, the nurse should remove gloves (Choice A) first. Gloves are considered contaminated and can harbor microorganisms. Removing them first helps prevent the spread of potential pathogens to other surfaces or items while removing other personal protective equipment (PPE).
Choice B rationale:
Goggles (Choice B) protect the eyes from splashes and airborne particles. However, they should be removed after gloves. Gloves have a higher potential for contamination due to direct contact with the client and the environment.
Choice C rationale:
Removing the gown (Choice C) should follow the removal of gloves and goggles. The gown provides a barrier against potential contaminants and should be taken off to prevent self-contamination while disrobing from other PPE.
Choice D rationale:
The mask (Choice D) should be removed last. It provides respiratory protection and prevents the nurse from inhaling airborne particles. Keeping the mask on while removing other PPE items helps maintain a barrier against potential exposure to respiratory pathogens.
Correct Answer is C
Explanation
Choice A rationale:
Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.
Choice B rationale:
Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.
Choice C rationale:
Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.
Choice D rationale:
Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.