A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Tachycardia

Cramping

Seizures

Elevated temperature

Answer and Explanation

The Correct Answer is C

Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.

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Correct Answer is B

Explanation

A.While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.

B.An error in fluid administration by an IV pump, especially when it involves delivering twice the prescribed amount, is a medication error that could have serious consequences, such as fluid overload or electrolyte imbalances. An incident report must be filed to document the event and investigate what went wrong with the equipment.

C.Removing wrist restraints one at a time, particularly when the client is calm, follows safe practice to prevent injury. This situation does not represent an error, violation, or adverse event, and does not require an incident report. Restraints should always be removed cautiously and gradually to ensure client safety.

D.A client vomiting after receiving an oral pain medication could be an adverse drug reaction. While this is important to document in the patient’s medical record, it may not always require an incident report unless it leads to further complications or indicates a medication error.

A. 7.5% B. 8.1% C. 13.3% D. 15%

Correct Answer is A

Explanation

To calculate the percentage of weight loss, we can use the formula:

Percentage of weight loss = (Weight loss / Original weight) * 100

Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:

Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%

The percentage of weight loss is approximately 7.49%.

Since none of the provided answer options exactly match this calculated percentage, the closest option is:

So, the nurse should identify the weight loss as approximately 7.5%.

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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

Correct Answer is B

Explanation

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is A

Explanation

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