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 A
Explanation
A. Assess the client.
This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.
B. Notify the nurse manager.
Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.
C. Complete an incident report.
After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.
D. Call the client’s provider.
If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.
Correct Answer is C
Explanation
A. Edema:
Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.
B. Heart Rate:
Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.
C. Chills
Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.
D. Pallor:
Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.
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