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 A
Explanation
A) Have the client sit up straight: This is the correct action. Sitting up straight helps ensure that the medication can be properly delivered to the nasal passages and increases the likelihood of effective absorption.
B) Leave the other nostril open while giving the medication: While it is often recommended to keep the opposite nostril open to allow for airflow, the medication should be delivered to one nostril at a time. The other nostril should typically be closed or pinched shut to direct the medication effectively.
C) Have the client tilt the head forward: This option is incorrect. Tilting the head forward can make it more difficult for the medication to reach the upper nasal passages. The client should usually keep their head in a neutral position or slightly tilted back.
D) Have the client squeeze the bottle while inhaling: This action is not ideal. The client should inhale gently while the nurse squeezes the atomizer to ensure that the medication is effectively distributed throughout the nasal passages. Squeezing the bottle should be coordinated with inhalation to achieve the best results.