A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

"My parent has type 2 diabetes mellitus."

"I wish my family was more supportive of my decision."

"I am not very good about taking prescribed medication."

"I had symptoms of asthma when I was a child."

Answer and Explanation

The Correct Answer is C

C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.

A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.

B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.

D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).

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Correct Answer is B

Explanation

B. Slowing the infusion rate of 0.9% sodium chloride and contacting the provider are appropriate initial actions to manage the client's dyspnea and hypertension, which are likely due to fluid overload from the IV infusion.

A Corticosteroids are not typically indicated for dyspnea and hypertension related to IV fluid administration with 0.9% sodium chloride.

C Changing the type of IV fluid to lactated Ringer's solution may be considered in some cases to address fluid balance issues. However, this decision should be made in consultation with the healthcare provider based on the client's specific clinical condition and fluid status.

D. Lowering the head of the bed to semi-Fowler's position can help improve respiratory function and reduce dyspnea. However, this action alone does not address the underlying cause of the client's symptoms.

A. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack B. A client who has a headache following a grade 1 concussion C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash D. A client who has experienced brain death and is awaiting organ procurement

Correct Answer is C

Explanation

C. Clients with this score may have altered consciousness and require close monitoring for changes in neurological status, respiratory function, and other complications. Placing this client closest to the nurses' station allows for prompt assessment and intervention if there is deterioration or emergent need.

A Clients with a score of 0 are generally stable and may not require immediate or intensive monitoring. Therefore, this client may not need to be placed closest to the nurses' station unless there are other medical considerations.

B. A grade 1 concussion is considered mild, and while the client may have symptoms such as headache, they are typically stable with minimal risk of deterioration. Monitoring for worsening symptoms is important, but this client may not require immediate proximity to the nurses' station unless symptoms worsen unexpectedly.

D. Clients who are brain dead and awaiting organ procurement are typically stable in terms of neurological status as they are no longer responsive. This client may not necessarily need to be closest to the nurses' station unless specific care needs arise.

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A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Correct Answer is C

Explanation

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