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.
Administer the prescribed PRN antihypertensive medication.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.
Correct Answer is B
Explanation
A. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.
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