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.

Potential Prescription: Anticipated /Nonessential /Contraindicated

Encourage the client to cough.

Keep the client's head in a midline position.

Elevate the head of the bed.

Assist the client to the bathroom.

Initiate seizure precautions.

Decrease oxygen to 1.5 L/min via nasal cannula.

Answer and Explanation

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

A)   Coughing is not directly related to the client's condition as described in the scenario.
B)   Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C)   Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D)   Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E)   Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F)   Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

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Free Nursing Study Resources

Correct Answer is ["A","D","E","F"]

Explanation

A) DKA can lead to several complications, including hypotension, which is indicated by the client's low blood pressure reading of 96/65 mm Hg.
B) Respiratory alkalosis is less likely because DKA typically leads to metabolic acidosis, as indicated by the low pH of 7.30.
C) DKA does not result in septic shock but it instead causes hypovolemic shock in case of severe dehydration.
D) Cardiac arrhythmias can occur due to the electrolyte imbalances, as evidenced by the high potassium level of 5.5 mEq/L.
E) Renal failure is another potential complication, suggested by the elevated creatinine level of 1.7 mg/dL. The client's hyperglycemia and dehydration can stress the kidneys, potentially leading to acute kidney injury or renal failure.
F) Cerebral edema is a less common but severe complication of DKA, especially in children and adolescents, and should be considered given the client's symptoms of frequent urination and extreme thirst. It results from over-hydration of the client.

A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom. D. Place a large-face clock in the client's bedroom.

Correct Answer is D

Explanation

A. Covering electrical outlets with tape may not be sufficient for safety and could pose a fire hazard. Safety covers designed for outlets are recommended.
B. Keeping the client's bedroom dark at night may increase confusion and disorientation. Soft lighting or nightlights are preferable.
C. While a calendar may be helpful, placing it in the client's bedroom may not be as beneficial as placing it in a common area where the client spends time during the day.Furthermore, amonthly calendar can be too complex for clients with Alzheimer’s disease, especially in the later stages. Simpler tools like a daily schedule or a weekly calendar are more effective.
D. A large-face clock can help the client orient to time and reduce confusion regarding the time of day.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["A","D","E","F"]

Explanation

A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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