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 ["45"]
Explanation
To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:
mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL
Plugging in the values from the question, we get:
mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL
Simplifying the equation, we get:
mL to administer = 60 mEq x 15 mL / 20 mEq
mL to administer = 45 mL
Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.
Correct Answer is ["2"]
Explanation
To administer the ordered dose of digoxin, you need to calculate how many tablets of the available strength are equivalent to 0.25 mg. You can use the formula:
Ordered dose / Available dose = Number of tablets
Plugging in the values, you get:
0.25 mg / 0.125 mg = 2 tablets
Therefore, you need to administer two tablets of digoxin 0.125 mg to give the ordered dose of 0.25 mg.
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