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: This is not the best action because it does not address the conflict between the client and the healthcare provider. The nurse should advocate for the client's wishes and seek a resolution that respects them.
Choice B Reason: This is not an appropriate action because it disregards the client's request and may give false hope. The nurse should respect the client's autonomy and dignity.
Choice C Reason: This is not a sufficient action because it does not ensure that the healthcare provider will comply with the client's request. The nurse should also involve other resources to help resolve the ethical dilemma.
Choice D Reason: This is the best action because it involves an impartial group of experts who can help mediate the situation and protect the client's rights. The nurse should seek ethical consultation when there is a disagreement about end-of-life decisions.
Correct Answer is C
Explanation
Choice A Reason: Cautioning the nurse that one more tardiness will result in probational employment is not the best approach because it is too punitive and does not address the underlying cause of the tardiness. The nurse manager should first try to understand why the nurse is late and offer support or guidance if needed.
Choice B Reason: Offering to switch the nurse's shift assignments to afternoons or evenings is not the best approach because it may not solve the problem of tardiness and may create resentment among other staff members who have to adjust their schedules. The nurse manager should respect the nurse's preferences and availability but also hold the nurse accountable for fulfilling their responsibilities.
Choice C Reason: This is the best approach because it communicates clearly and respectfully what is expected of the nurse and why it is important for them to be punctual. The nurse manager should also provide feedback and recognition when the nurse improves their attendance.
Choice D reason: Having the nurse sign a copy of the hospital employee attendance policy is not the best approach because it may imply that the nurse is unaware or indifferent to the policy. The nurse manager should assume that the nurse knows and agrees with the policy, but may need some assistance or motivation to follow it.
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