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?
Place the client on contact precautions.
Start a high-fiber diet.
Administer an oral steroid.
Make the client NPO.
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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Correct Answer is B
Explanation
Choice A rationale
Giving the client a hug may not be appropriate in a professional setting and could be perceived as crossing personal boundaries.
Choice B rationale
While touching the client’s forearm, asking “Would you like to talk about it?” is a compassionate and supportive response. It shows empathy and provides the client with an opportunity to express their feelings.
Choice C rationale
Apologizing for disturbing the client and offering to wait until later may not address the client’s immediate emotional needs.
Choice D rationale
Stating that it is a bad time and offering to come back later may not provide the client with the support they need in the moment.
Correct Answer is A
Explanation
Choice A rationale
Having the client demonstrate prescribed wound care is the most effective method to evaluate the client’s understanding of self-care at home. This approach allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide immediate feedback and clarification as needed. Demonstration ensures that the client can correctly follow the wound care instructions, which is crucial for proper healing and preventing complications.
Choice B rationale
Asking the client if they understand after each instruction may not be effective, especially if the client is not comfortable expressing confusion or misunderstanding. This method relies on the client’s verbal confirmation, which may not accurately reflect their ability to perform the wound care tasks correctly.
Choice C rationale
Having an interpreter repeat the wound care instructions can help bridge the language barrier, but it does not allow for direct observation of the client’s ability to perform the necessary tasks. While the interpreter can ensure that the client understands the instructions, it does not provide the nurse with a way to assess the client’s practical skills.
Choice D rationale
Providing written instructions in the client’s native language can be helpful, but it does not allow the nurse to directly evaluate the client’s understanding and ability to perform the wound care tasks. Written instructions alone may not be sufficient for clients who have limited literacy or who may have difficulty following written directions.