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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 A

Explanation

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure accurate readings. Incorrect placement can lead to false low oxygen saturation readings.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, it is not the immediate first step.

Choice C rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient.

Choice D rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia.

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.

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