An older adult client arrives to the emergency department after experiencing two days of fever, nausea, and vomiting. The client gives the nurse a bag of home medications and reports a history of insulin dependent diabetes mellitus with an onset of blurred vision. Which intervention should the nurse implement first?

Establish mental status baseline.

Insert an indwelling urinary catheter.

Check the accuracy of medication list.

Obtain a capillary blood glucose level.

Answer and Explanation

The Correct Answer is D

A.   While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B.   Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C.   Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D.   Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

Nursing Test Bank

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Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Listen to the ethics committee discussions and then inform the client what actions should be taken. C. Challenge members of the healthcare team whose opinions differ from the wishes of the client. D. Educate the client about current nursing literature findings related to the client's ethical dilemma.

Correct Answer is A

Explanation

A. Developing self-awareness of personal values is crucial for a nurse acting as an advocate. It ensures
that the nurse’s own beliefs and biases do not interfere with representing the client's wishes and values. This self-awareness helps the nurse advocate effectively for the client’s preferences and decisions without imposing their own personal values.
B. While listening to the ethics committee discussions is important for understanding the context of the ethical dilemma, informing the client about what actions should be taken might not align with the nurse’s role as an advocate. The nurse's role is to represent the client's wishes and interests, not to dictate actions based on the committee’s deliberations.
C. It is important to ensure the client’s wishes are represented, but challenging team members should be done respectfully and constructively. The nurse should focus on presenting the client’s viewpoint clearly and facilitating a discussion that considers the client’s preferences.
D. Educating the client about current literature can be helpful, but it is not the primary responsibility of the nurse in the role of an advocate at an ethics committee meeting. The nurse’s primary role is to
represent the client’s wishes and ensure their voice is heard in the ethical decision-making process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

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