A nurse is reviewing the prescriptions for a client who has a new diagnosis of bacterial meningitis. Which of the following prescriptions should the nurse clarify with the provider?
Place the client on droplet precautions.
Perform a cranial nerve assessment on the client every 2 hr.
Assist the client out of bed three times per day.
Assess the client's weight daily.
The Correct Answer is B
Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Dispose of the client's feces and urine in a special container.
Choice A rationale:
This is the correct choice. Brachytherapy involves the placement of a radiation source in or near the tumor. To minimize radiation exposure to others, the client's bodily fluids (feces and urine) should be considered radioactive and disposed of properly in a designated container.
Choice B rationale:
While limiting the time of visitors can be a good measure to reduce radiation exposure, it is not the priority intervention. The primary concern is proper handling and disposal of radioactive bodily fluids.
Choice C rationale:
Keeping the client's linens in the room until after removal of the radiation source is not the correct choice. Radioactive linens should be handled and laundered separately, following appropriate safety protocols.
Choice D rationale:
Providing one dosimeter badge for staff to share while caring for the client is not adequate. Each staff member involved in direct care should have their dosimeter badge to monitor their individual radiation exposure levels.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.
Choice B rationale:
Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.
Choice C rationale:
Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.
Choice D rationale:
Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.
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