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 D
Explanation
Choice A rationale
Determining the client’s activity tolerance is important but should follow the initial assessment of the client’s ability to perform ADLs safely.
Choice B rationale
Teaching the client to shorten the stride to prevent falls is not necessary if the client’s gait is smooth and steady. This intervention is more appropriate for clients with gait instability.
Choice C rationale
Initiating a fall risk protocol for the client is not necessary if the client’s gait is smooth and steady. This protocol is more appropriate for clients with a higher risk of falls.
Choice D rationale
Recording the client’s ability to perform ADLs safely is the next appropriate action. This documentation is essential for the care plan and ensures that the client’s current status is accurately reflected.
Correct Answer is D
Explanation
Choice A rationale
Stating that the healthcare provider will share the information does not address the legal status of the emancipated minor and may delay the communication of important information.
Choice B rationale
Telling the parents that their child’s medical information is none of their business is not respectful and does not provide a clear explanation of the legal situation.
Choice C rationale
Offering to give the results to the parents as soon as they are available does not respect the legal autonomy of the emancipated minor.
Choice D rationale
Explaining that medical information can only be given to the client because they are legally an adult is the best response. It respects the legal status of the emancipated minor and their right to make their own healthcare decisions