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 C
Explanation
Rationale:
A. Milk: Milk does not interfere with fecal occult blood testing and does not contain substances that cause false-positive results. It can be safely consumed prior to the test without affecting the accuracy of the results.
B. Whole wheat bread: Whole wheat bread is high in fiber, which is actually beneficial when preparing for a fecal occult blood test. It helps promote regular bowel movements but does not lead to false-positive results.
C. Red meat: Red meat contains heme, a form of animal blood, which can cause false-positive results on guaiac-based fecal occult blood tests. Avoiding red meat for at least 3 days prior to the test helps reduce the risk of inaccurate results.
D. Almonds: Almonds and other nuts do not contain components that interfere with fecal occult blood testing. They are not known to cause false-positive or false-negative results and are safe to consume before the test.
Correct Answer is B
Explanation
Rationale:
A. Encourage the client to increase fluid intake: Clients receiving continuous peritoneal dialysis may need to restrict fluids to prevent volume overload, depending on residual kidney function and dialysis efficiency. Encouraging increased intake without provider orders can be harmful.
B. Obtain the client's weight: Daily weight is a critical indicator of fluid balance and dialysis effectiveness. Monitoring weight helps determine if the dialysis is removing the appropriate amount of fluid and supports adjustments to the treatment plan.
C. Palpate the access site for a thrill: A thrill is a vibration felt over an arteriovenous fistula, which is used in hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a soft catheter in the abdomen and does not produce a thrill.
D. Auscultate the access site for a bruit: A bruit, a whooshing sound heard over a vascular access, is associated with AV fistulas used in hemodialysis. It is not relevant for peritoneal dialysis, which uses a catheter and does not involve high-pressure blood flow.
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