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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Round and Taut:
A round and taut abdomen may be normal, depending on the individual's body habitus and muscle tone. It might indicate normal abdominal distension associated with gas or a meal.
B. White Striae (Stretch Marks)
White striae, commonly known as stretch marks, on the abdomen may warrant further investigation. While they are often benign and associated with conditions like weight gain or pregnancy, they can sometimes be indicative of underlying issues such as Cushing's syndrome or other factors. Further inquiry or investigation into the client's medical history may be needed to understand the cause of the white striae.
C. Symmetrical, Rounded Shape:
A symmetrical and rounded abdominal shape is generally considered a normal finding. It suggests that the abdominal muscles are intact and that there is no obvious asymmetry or abnormal protrusion.
D. Soft and Non-Tender:
A soft and non-tender abdomen is a normal finding. It suggests that the abdominal
Correct Answer is B
Explanation
A. Change the plan of care to provide different pain relief interventions:
While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.
B. Reassess the client to determine the reasons for inadequate pain relief.
Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.
C. Teach the client about the plan of care for managing his pain:
Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.
D. Wait to see whether the pain lessens during the next 24 hours:
If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.
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