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 C
Explanation
Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA).
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA).
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA).
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.