The nurse begins a shift on a busy medical-surgical unit and will be caring for multiple clients. Which client does the nurse assess first?
A client who has a question about her daily medications
A client who needs discharge teaching about an antibiotic
A client who just received nitroglycerin for chest pain
A client who would like some acetaminophen (Tylenol) for a mild headache
The Correct Answer is C
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.
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Correct Answer is D
Explanation
A) While administering the eye drops, a drop lands on the client's outer lid, so the client administers another drop: This action requires further teaching. If a drop lands outside the eye, the client should not administer another drop without first cleaning the area. It’s important to avoid excessive dosing and to ensure the medication is delivered properly.
B) The client cleans the eye from the inner to the outer canthus: This is the correct technique. Cleaning the eye from the inner canthus to the outer canthus helps prevent the spread of debris and ensures a clean area for administering drops.
C) The client looks upward toward the ceiling and administers the eye drops in the conjunctival sac: This action is appropriate. Looking upward helps expose the conjunctival sac, making it easier to administer the drops effectively.
D) The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location: This action requires further teaching. Touching the conjunctival sac with the eyedropper can introduce bacteria and lead to contamination or injury. The client should be advised to keep the dropper tip away from the eye to maintain sterility and safety.
Correct Answer is C
Explanation
A) 6 weeks from the start of using the inhaler: This option is not accurate. The timing for refilling should be based on the actual usage rather than a fixed period, and 6 weeks may not align with the client’s actual consumption.
B) As soon as the client leaves the hospital: This option is premature. The client does not need to refill the inhaler immediately upon discharge since they may not have used many puffs yet.
C) 50 days after discharge: This is the correct answer. If the client is to administer 2 puffs twice daily, that totals 4 puffs per day. With 200 puffs in the inhaler, the inhaler would last for 50 days (200 puffs ÷ 4 puffs per day = 50 days). Advising the client to refill the medication approximately 50 days after discharge ensures they have enough medication available.
D) When the inhaler is half empty: This option could lead to refilling too early or too late, depending on the individual’s usage pattern. Advising to refill based on a specific number of days or puffs used provides a more precise recommendation.