The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?
Advise the UAP to stop providing care so the nurse can assess the client's condition.
Determine why the UAP did not notify the nurse of the change in the client's condition.
Ask the UAP to position the client so the oral medications can be administered.
Explain to the UAP that changes in a client's condition should be reported immediately.
The Correct Answer is A
A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.
B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.
C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.
D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds: Paralytic ileus is common postoperatively and, while concerning, is usually not immediately life-threatening.
B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity: Abdominal rigidity suggests possible bowel ischemia or perforation, which are surgical emergencies. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.
C. The client with an obstruction of the large intestine who is experiencing abdominal distention: While abdominal distention indicates obstruction, it is not immediately life-threatening unless accompanied by signs of ischemia or perforation.
D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid: NG drainage is expected with small bowel obstruction and indicates decompression is occurring. This is less urgent than a client showing signs of peritonitis.
Correct Answer is ["A","D","E"]
Explanation
A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.
B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.
C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.
D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.
E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.
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