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 D
Explanation
Choice A Reason: A client with multisystem failure secondary to a motor vehicle collision is not an appropriate assignment for the new graduate nurse. This client has complex and unstable needs that require advanced assessment, intervention, and evaluation skills. The nurse should assign this client to a nurse with 10 years experience, who has more expertise and confidence in managing critically ill clients.
Choice B Reason: A client in end-stage liver failure who is experiencing esophageal bleeding is not an appropriate assignment for the new graduate nurse. This client has a high risk of complications such as hemorrhage, infection, hepatic encephalopathy, and hepatic coma. The nurse should assign this client to a nurse with 5 years experience, who has more knowledge and skill in providing palliative care and managing bleeding disorders.
Choice C Reason: A client with Adult Respiratory Distress Syndrome who is on a ventilator is not an appropriate assignment for the new graduate nurse. This client has a life-threatening condition that requires close monitoring of respiratory status, oxygenation, and hemodynamics. The nurse should assign this client to a nurse with 10 years of experience, who has more competence and proficiency in caring for ventilated clients and interpreting data from invasive devices.
Choice D Reason: A client with chest tubes secondary to a stab wound to the chest is an appropriate assignment for the new graduate nurse. This client has a relatively stable condition that requires routine care of chest tubes, pain management, and wound healing. The nurse should assign this client to the new graduate nurse, who has learned the basic principles and techniques of chest tube management during the refresher course and the internship. The charge nurse should also provide supervision and support to the new graduate nurse as needed.
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it prevents the spread of infection to other clients and staff. Mumps is a viral infection that causes inflammation of the salivary glands and can be transmitted by respiratory droplets. The nurse should place an isolation cart outside of the room and wear a mask, gloves, and gown when entering.
Choice B Reason: This is not the first priority because it does not address the risk of infection. The nurse should schedule bedside play time with the occupational therapist to promote the child's development and coping, but this can be done later.
Choice C Reason: This is not the first priority because it does not ensure that infection control measures are in place. The nurse should instruct the child's parents about the need for transmission precautions and educate them on how to care for their child at home, but this can be done later.
Choice D Reason: This is not the first priority because it does not prevent the spread of infection. The nurse should assign the child to a room close to the nurse's station to monitor his condition and provide comfort, but this is not a critical intervention.
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