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A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A.

Encourage the client to cough.

B.

Initiate seizure precautions.

C.

Elevate the head of the bed.

D.

Keep the client's head in a midline position.

E.

Decrease oxygen to 1.5 L/min via nasal cannula.

F.

Assist the client to the bathroom.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Rationale

Interpretation of Actions:

  • Encourage the client to cough:
    • Nonessential
      Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
  • Initiate seizure precautions:
    • Anticipated
      Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
  • Elevate the head of the bed:
    • Anticipated
      Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
  • Keep the client's head in a midline position:
    • Anticipated
      Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
  • Decrease oxygen to 1.5 L/min via nasal cannula:
    • Contraindicated
      Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
  • Assist the client to the bathroom:
    • Contraindicated
      Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

  • Pink-tinged urine:
    • Indication of potential worsening condition
      Pink-tinged urine may indicate bleeding in the urinary tract, which could be a complication of the urinary tract infection (UTI) or another underlying issue.
  • Hct 45%:
    • Indication of potential improvement
      The hematocrit has decreased from 50% to 45%, suggesting improved hydration status, as the previous elevated Hct was likely due to hemoconcentration.
  • Butterfly rash:
    • Unrelated to diagnosis
      The butterfly rash is a hallmark sign of systemic lupus erythematosus (SLE), part of the client's medical history, but it is unrelated to the current UTI diagnosis.
  • Oxygen saturation 96% at 2 L/min via nasal cannula:
    • Indication of potential improvement
      The oxygen saturation has improved from 95% on 3 L/min to 96% on 2 L/min, suggesting better respiratory status and gas exchange.
  • Blood pressure 100/50 mm Hg:
    • Indication of potential worsening condition
      The blood pressure has decreased from 106/64 mm Hg to 100/50 mm Hg, which may indicate worsening perfusion or ongoing dehydration.
  • Disoriented to person, place, and time:
    • Indication of potential worsening condition
      The client was previously oriented to person and place but is now disoriented. This could indicate worsening infection, progression to sepsis, or other complications such as hypoxia or electrolyte imbalance.

Correct Answer is D

Explanation

A. While checking the client’s vital signs is important, it is not the first action the nurse should take. The priority is to stop the transfusion immediately to prevent further harm.

B. Administering oxygen may be necessary if the client’s condition worsens, but stopping the transfusion is the first step in addressing the potential transfusion reaction.

C. Collecting a urine sample may be important if hemolysis is suspected, but the first priority is to stop the transfusion to prevent further damage.

D. The symptoms of chills, back pain, and nausea are indicative of a potential transfusion reaction, such as hemolytic reaction. The nurse’s first action is to stop the transfusion to prevent further complications. After stopping the infusion, the nurse should notify the provider, monitor the client’s vital signs, and assess for additional symptoms.

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