A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Hold the client's evening dose of digoxin.

Increase the client's fluid intake.

Complete a neurological check.

Administer the prescribed PRN antihypertensive medication.

Answer and Explanation

The Correct Answer is C

A.   Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B.   Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C.   Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D.   Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.

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Correct Answer is B

Explanation

A. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.

A. Elevate the bed to a position of comfort for the nurse. B. Acquire the help of several people to lift the client. C. Place the wheelchair at a 90° angle to the bed. D. Lock the wheels of the bed and the wheelchair.

Correct Answer is D

Explanation

- A) Elevating the bed to a comfortable position for the nurse is important to prevent strain or injury to the nurse's back. However, this action alone does not ensure the client's safety during the transfer.
- B) While acquiring help can be useful, especially for a heavy client or one with limited mobility, it is not the primary action to ensure safety during the transfer.
- C) Placing the wheelchair at a 90° angle to the bed may make the transfer more difficult because it does not allow for the most direct path to the wheelchair.
- D) Locking the wheels of both the bed and the wheelchair is the correct action to take to ensure stability and prevent movement, providing a safe transfer for the client.

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A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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