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 D
Explanation
A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.
Correct Answer is B
Explanation
A. Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.