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 C

Explanation

A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

A. RBC count B. WBC count C. Potassium D. BUN

Correct Answer is B

Explanation

A. An elevation in the red blood cell (RBC) count is not a specific indication of infection. It primarily reflects oxygen-carrying capacity.
B. An elevation in the white blood cell (WBC) count is an indication of infection. When the body is fighting an infection, the number of white blood cells increases as part of the immune response.
C. Potassium is an electrolyte and is not a specific marker for infection. Abnormal potassium levels may indicate a variety of conditions, but they do not directly indicate infection.
D. Blood urea nitrogen (BUN) is a marker of kidney function and is not a specific indicator of infection. Elevated BUN levels can be seen in various kidney and non-kidney-related conditions.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

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