The nurse has reviewed the provider prescriptions at 1045.

Which of the following actions should the nurse perform first?

Apply dressing to foot wound.

Consult outpatient wound care specialist.

Schedule appointment with ophthalmologist.

Administer regular insulin 4 units subcutaneously x 1 dose

Answer and Explanation

The Correct Answer is D

Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.

Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.

Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.

Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.

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Correct Answer is ["B","E"]

Explanation

A. Place a tongue blade at the bedside: Keeping a tongue blade at the bedside is not recommended because attempting to insert an object into the mouth during a seizure can cause injury to the teeth, gums, or airway. Instead, the focus should be on maintaining a safe environment and protecting the client from harm.

B. Dim the overhead lights: Meningitis can cause photophobia, or sensitivity to light, which can worsen discomfort and potentially trigger seizures. Dimming the lights helps reduce sensory stimulation and promotes comfort, decreasing the risk of further neurological agitation.

C. Assist the client to ambulate every 4 hr: Clients experiencing seizures should have activity restrictions to prevent falls and injuries. Ambulation should be supervised and only encouraged once the client is stable. Frequent rest is preferred to minimize exhaustion, which can contribute to seizure activity.

D. Apply a warming blanket: Meningitis can cause fever, but applying a warming blanket is not appropriate unless the client is experiencing hypothermia. Fever management typically involves antipyretics and cooling measures, such as tepid sponge baths or light clothing, rather than warming interventions.

E. Have suction equipment at the bedside: During a seizure, excessive secretions or impaired airway protection can lead to aspiration. Having suction equipment readily available allows for quick clearance of the airway once the seizure subsides, reducing the risk of respiratory complications.

A. Discontinue opioids before trying nonpharmacological methods of pain relief. B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus. C. Use imagery with clients who have difficulty with focus and concentration. D. Distraction changes the client's perception of pain, but it does not affect the cause.

Correct Answer is D

Explanation

A. Discontinue opioids before trying nonpharmacological methods of pain relief: Nonpharmacological interventions can be used alongside opioids to enhance pain relief. Abruptly discontinuing opioids can lead to withdrawal symptoms and inadequate pain control.

B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: While heat and cold therapy can provide temporary relief, their effects typically last for a short duration, usually around 15 to 30 minutes after removal.

C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires cognitive focus and the ability to concentrate. Clients with impaired attention may struggle to benefit from this technique.

D. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques, such as music or conversation, help shift the client's attention away from pain, altering perception but not addressing the underlying pathology.

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The nurse has reviewed the provider prescriptions at 1045. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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Correct Answer is D

Explanation

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The nurse has reviewed the provider prescriptions at 1045.

Which of the following actions should the nurse perform first?