The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data.
Complete the following sentence by using the list of options.
The nurse should first plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale:
• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.
• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.
• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.
• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.
• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.
• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.
B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.
C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.
D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.
Correct Answer is B
Explanation
Rationale:
A. "Colostrum provides vitamin K which is an essential nutrient for newborns." While vitamin K is essential for clotting, it is not found in sufficient amounts in colostrum. This is why newborns routinely receive a vitamin K injection shortly after birth, rather than relying on breast milk as a source.
B. "Colostrum provides many important antibodies that the newborn lacks." Colostrum is rich in immunoglobulins, especially IgA, which help protect the newborn from pathogens by providing passive immunity. These antibodies line the infant's gastrointestinal tract and offer critical defense during early life.
C. "Colostrum contains iron, which is important for a newborn's brain development." Although breast milk contains iron, colostrum is not a major source of it. Newborns are typically born with adequate iron stores to last several months, and the primary role of colostrum is immune protection, not iron supplementation.
D. "Colostrum contains a natural diuretic that stimulates the newborn to void." While colostrum has a laxative effect that helps the newborn pass meconium, there is no known diuretic component. Its primary importance lies in delivering antibodies and coating the GI tract to reduce infection risk.
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