A nurse is caring for a client who is near death. Which of the following actions should the nurse take?
Administer scheduled pain medications
Provide oral care every 6 hours.
c) Administer liquids using a syringe.
Whisper when talking to family members.
The Correct Answer is A
The nurse should administer scheduled pain medications to a client who is near death. This is an important nursing intervention to ensure that the client is comfortable and free from pain.
b) Providing oral care every 6 hours is important, but it may not be the highest priority for a client who is near death.
c) Administering liquids using a syringe may not be necessary or appropriate for a client who is near death.
d) Whispering when talking to family members is not necessary. The nurse should communicate openly and honestly with the family members.
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Related Questions
Correct Answer is C
Explanation
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
Correct Answer is D
Explanation
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
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