A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?
Develop a plan of care for the client
Provide a schedule of visiting hours to the client’s family
Teach the client about his diagnosis
Document the client’s code status
The Correct Answer is D
A. Develop a plan of care for the client:
Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.
B. Provide a schedule of visiting hours to the client’s family:
While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.
C. Teach the client about his diagnosis:
Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.
D. Document the client’s code status
When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.
Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place the client on bed rest in supine position:
While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.
B. Repeat auscultation after asking the client to breathe deeply and cough:
This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.
C. Prepare to administer antibiotics:
Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.
D. Instruct the client to limit fluid intake to less than 2,000 mL/day:
Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.
Correct Answer is ["6"]
Explanation
To calculate the amount of ampicillin needed for one dose, we need to use a proportion. We can set up the proportion as follows:
150 mg / x mL = 125 mg / 5 mL
We can cross-multiply and solve for x:
150 * 5 = 125 * x
750 = 125 * x
x = 750 / 125
x = 6
Therefore, we need 6 mL of ampicillin for one dose
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