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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Noncompliance with treatment regimen: While noncompliance can affect recovery, it is secondary to the immediate physiological risks posed by malnutrition. Addressing noncompliance becomes relevant after stabilizing the client’s health.

B. Disturbed Body Image: Distorted body image is a core psychological issue in anorexia nervosa, but it does not pose an immediate threat to the client’s life. Interventions targeting body image are important but not the first priority.

C. Interrupted Family Processes: Family dynamics may influence the client’s condition and recovery, yet they are not life-threatening. Family interventions are supportive and adjunctive to stabilizing the client’s nutritional status.

D. Imbalanced Nutrition: less than body requirements: Malnutrition directly threatens the adolescent’s physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Correcting nutritional deficits and preventing complications such as electrolyte imbalance or organ failure is the highest priority in care planning.

A. Place a warm blanket on the client. B. Administer IV fluids per protocol. C. Review the medication administration record. D. Check the urinary catheter r an occlusion.

Correct Answer is B

Explanation

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is D

Explanation

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Correct Answer is B

Explanation

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?