A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?
A client who has type 2 diabetes mellitus needs assistance counting the carbohydrates in her meal.
A client who has a new tracheostomy is experiencing coughing episodes.
A client who has a BMI of 17 refuses his dinner tray.
A client awaiting discharge needs to demonstrate colostomy care before leaving.
The Correct Answer is B
A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.
Correct Answer is B
Explanation
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.