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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

A.

Place the client on contact precautions.

B.

Start a high-fiber diet.

C.

Administer an oral steroid.

D.

Make the client NPO.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.

 

Choice B rationale

 

Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.

 

Choice C rationale

 

Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.

 

Choice D rationale

 

Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.
 


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.

Choice B rationale

Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.

Choice C rationale

Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.

Choice D rationale

Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

Correct Answer is A

Explanation

Choice A rationale

Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart.

Choice B rationale

Regular exercise is a beneficial lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While exercise helps in maintaining a healthy weight, reducing blood pressure, and improving overall cardiovascular health, smoking cessation has a greater impact on reducing the risk of cardiovascular events and mortality.

Choice C rationale

A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although a low-fat diet helps in lowering cholesterol levels and reducing the risk of heart disease, smoking cessation has a stronger influence on lowering the levels of cholesterol and inflammation in the blood.

Choice D rationale

Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease.

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