Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?
Administer an antianxiolytic medication.
Insert fecal management tube.
Insert peripheral intravenous catheter.
Crush pills and place in applesauce.
The Correct Answer is C
Choice A rationale: Administering an antianxiolytic medication may be appropriate, but addressing the client's fluid and electrolyte imbalance is the priority.
Choice B rationale: Inserting a fecal management tube is not the first action to take in response to hemoccult positive liquid stools; addressing fluid balance is more urgent.
Choice C rationale: Inserting a peripheral intravenous catheter is the priority to address the client's fluid and electrolyte imbalance and provide necessary hydration and medications.
Choice D rationale: Crushing pills and placing them in applesauce may be considered, but the client's fluid and electrolyte imbalance needs prompt attention first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Waiting for the client to respond allows for a patient-centered approach, respecting the client's pace and giving them the opportunity to express themselves when ready.
Choice B rationale: Assuming the client's ability to hear the question may be accurate, but the client's nonverbal cues suggest a need for patience and a non-coercive approach.
Choice C rationale: Changing the question may not address the client's current feelings and might disrupt the therapeutic process.
Choice D rationale: Returning at a later time might be appropriate if the client continues to be unresponsive, but it is not the initial action in this situation.
Correct Answer is D
Explanation
Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.
Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.
Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.
Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.