Exhibits
A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?
Initiate an IV access for the client.
Administer pain medication to the client.
Send the client to radiology for a CT scan.
Insert an NG tube for the client.
The Correct Answer is A
A. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.
Correct Answer is ["C","D"]
Explanation
A. illusions aren’t common in delirium
B. the client’s past medical history isn’t indicative of delirium.
C. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.
D. Delirium can manifest as disorientation, confusion, agitation, restlessness, illusions, or hallucinations. It can also impair memory, judgment, and language.
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