A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
A client who has orthostatic hypotension and is receiving IV fluids
A client who has Type 1 diabetes and uses an insulin pump
A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
A client who is receiving heparin and has an aPTT of 34 seconds
The Correct Answer is D
Choice A reason: This client does not need an interdisciplinary conference because their condition is not complex or chronic. The nurse can manage the client's care by monitoring their vital signs, fluid intake and output, and hydration status. The nurse can also educate the client on how to prevent orthostatic hypotension by changing positions slowly and wearing compression stockings.
Choice B reason: This client does not need an interdisciplinary conference because their condition is well-controlled and self-managed. The nurse can manage the client's care by checking their blood glucose levels, administering insulin as prescribed, and providing dietary and lifestyle education. The nurse can also collaborate with the diabetes educator or the endocrinologist if needed.
Choice C reason: Although this client is at risk for pressure ulcers, their albumin level is within the normal range, indicating adequate nutritional status. Low albumin levels are often associated with poor wound healing and increased risk of skin breakdown, but in this case, nutrition does not appear to be a concern. Preventive measures, such as regular repositioning, skin assessments, and pressure-relieving devices, can be implemented by nursing staff without requiring an interdisciplinary meeting.
Choice D reason: This client is the most appropriate candidate for an interdisciplinary conference. The activated partial thromboplastin time (aPTT) is a critical lab value for monitoring heparin therapy, and a level of 34 seconds is below the therapeutic range. A subtherapeutic aPTT increases the risk of clot formation, indicating that the heparin dose may need to be adjusted. An interdisciplinary team, including the physician, pharmacist, nurse, and laboratory personnel, should collaborate to ensure safe and effective anticoagulation management. This conference would allow for a discussion on dosage adjustments, potential medication interactions, and continued monitoring to prevent complications such as deep vein thrombosis or pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
Correct Answer is D
Explanation
Choice A reason: Beneficence is the ethical principle of doing good or acting in the best interest of others. While this is an important principle for nurses to follow, it does not directly apply to the situation of reporting the truth about the incident.
Choice B reason: Nonmaleficence is the ethical principle of avoiding harm or minimizing the risk of harm to others. This principle is relevant to the prevention of falls and the use of gait belts, but it does not address the issue of honesty in documentation.
Choice C reason: Fidelity is the ethical principle of being faithful or loyal to one's commitments and responsibilities. This principle relates to the nurse's duty to provide safe and competent care to the client, but it does not specify the obligation to report the facts accurately.
Choice D reason: Veracity is the ethical principle of telling the truth or being truthful. This principle is the most appropriate for the charge nurse to follow in this case, as it requires the nurse to report the incident honestly and completely, including the omission of the gait belt. This is essential for quality improvement, legal protection, and ethical accountability.
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