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","F","G","H"]
Explanation
A. Notify the social worker the client is awake: The social worker is already attempting to contact family. Awakening does not require immediate notification; the priority is client care and stabilization.
B. Explain all procedures: As the client becomes more alert, clear explanations reduce anxiety, promote cooperation, and support orientation, especially in the ICU environment.
C. Increase the propofol infusion: Increasing sedation without clinical indication may mask neurological changes and hinder assessment. Sedative adjustments should be based on prescribed parameters and provider orders.
D. Consider extubating the client: Extubation is only considered when specific respiratory and hemodynamic criteria are met. Waking up does not automatically mean the client is ready to be extubated.
E. Have the client sign consent forms for procedures already performed: Consent must be obtained prior to procedures. Once completed, retroactive consent is not valid or ethical.
F. Assess the client’s pain: Pain assessment is essential in postoperative and trauma patients, particularly once the client is able to communicate.
G. Determine the client’s decision-making ability: As the client becomes more awake, assessing cognitive status and ability to participate in care decisions is appropriate and supports autonomy.
H. Decrease the noise and light stimuli in the room as much as possible: Minimizing environmental stimuli helps reduce delirium risk, improves comfort, and promotes healing in critically ill patients.
Correct Answer is B
Explanation
A. Tell the client that the medication's side effects will most likely dissipate over time: While side effects may lessen with continued use, this response does not address the client’s intent to stop the medication safely.
B. Inform the client that gradual tapering must be used to discontinue the medication: Abrupt discontinuation of antidepressants can lead to withdrawal symptoms and risk of relapse. Educating the client about the need for a gradual taper ensures safe discontinuation and continuity of care.
C. Remind the client that feeling better is the therapeutic effect of the medication: Acknowledging the therapeutic benefit is important but does not provide guidance on safely stopping the medication or addressing the client’s concerns.
D. Tell the client to discuss the medication side effects with the healthcare provider (HCP): Encouraging communication with the HCP is appropriate, but the immediate priority is to inform the client that discontinuation must be gradual to prevent adverse effects.
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