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?

Explain to the UAP that changes in a client's condition should be reported immediately.

Advise the UAP to stop providing care so the nurse can assess the client's condition. C

Ask the UAP to position the client so the oral medications can be administered.

Determine why the UAP did not notify the nurse of the change in the client's condition.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B)   Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C)   Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D)   Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

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Correct Answer is A

Explanation

The information that the nurse should obtain from the client first is: Reason for taking the aspirin.

It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.

By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.

Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.

A. Use standard precautions and wear a mask. B. Monitor the client's white blood cell count. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Explain the purpose of a low-bacteria diet.

Correct Answer is ["B","C","D"]

Explanation

A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

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? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)