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.
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Correct Answer is D
Explanation
A. While it's a good idea to rotate nonperishable food items to ensure freshness, the recommendation is typically to check them periodically rather than replace them annually, making this statement less accurate for disaster preparedness.
B. Having a backup supply of nonprescription medications is beneficial, but this is not a primary recommendation for disaster preparedness and may not specifically apply to all older adults.
C. The standard recommendation is to stock at least 1 gallon of water per person per day, not 2 liters, which is less than the recommended amount for hydration and other needs during emergencies.
D. Gathering enough supplies to last for 2 weeks is an essential component of disaster preparedness, especially for older adults who may have specific health needs and may not have easy access to supplies during a disaster.
Correct Answer is A
Explanation
A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.