Which client requires the most immediate intervention by the nurse?
An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
A client with acute kidney injury who is somnolent and does not respond to verbal commands.
A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
The Correct Answer is B
A) This client has a mild fever, which may indicate an infection or inflammation. This is a potential complication of enteral feedings, but it is not the most urgent situation. The nurse should monitor the client's vital signs, assess the feeding tube site, and notify the provider if the fever persists or worsens.
B) This client has signs of uremic encephalopathy, which is a life-threatening condition caused by the accumulation of toxins in the brain due to impaired renal function. The nurse should intervene immediately to prevent further
neurological damage and possible coma or death. The nurse should assess the client's level of consciousness, check the blood pressure and urine output, and prepare to administer dialysis or other treatments as ordered by the provider.
C) This client has heat stroke, which is a serious condition that can lead to dehydration, electrolyte imbalance, and organ damage. However, the client is receiving a normal saline IV fluid bolus, which is an appropriate intervention to restore fluid volume and correct sodium levels. The nurse should continue to monitor the client's vital signs, skin
temperature, and urine output, and watch for signs of fluid overload or cerebral edema.
D) This client has hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, malnutrition, and electrolyte imbalance. However, the client is receiving an infusion of Ringer's Lactate, which is an isotonic solution that can replenish fluid and electrolyte losses. The nurse should continue to monitor the client's vital signs, weight, and intake and output, and administer antiemetics or other medications as ordered by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ceftriaxone is an antibiotic that can be given by gravity infusion without an IV pump, as long as the nurse monitors the flow rate and adjusts the roller clamp as needed. The dose and duration of ceftriaxone are usually fixed and not affected by minor fluctuations in the infusion rate.
Choice B reason: Heparin is an anticoagulant that requires a precise and constant infusion rate to prevent bleeding or clotting complications. An IV pump is essential to deliver heparin safely and accurately.
Choice C reason: Magnesium is an electrolyte that can cause serious adverse effects such as cardiac arrhythmias,
respiratory depression, and muscle weakness if infused too rapidly or too slowly. An IV pump is necessary to control the infusion rate and prevent magnesium toxicity or deficiency.
Choice D reason: Regular insulin is a hormone that regulates blood glucose levels and requires careful titration based on frequent blood glucose monitoring. An IV pump is required to deliver insulin at a consistent and adjustable rate to avoid hypoglycemia or hyperglycemia.
Correct Answer is D
Explanation
Choice A Reason: This is not the first action because it does not address the safety risk of smoking in the hospital. The nurse should document the occurrence after taking appropriate measures to prevent fire and injury.
Choice B Reason: This is not the first action because it does not stop the client from smoking in the bathroom. The nurse should obtain a prescription for a nicotine patch if the client agrees to quit smoking, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not ensure that the client will comply with the hospital smoking policy. The nurse should educate the client about the health hazards of smoking and the hospital rules, but this can be done later.
Choice D Reason: This is the best action because it alerts the authority figure who can intervene and enforce the hospital smoking policy. The nurse should notify the charge nurse as soon as possible to prevent fire and injury.
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