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 C
Explanation
A) Application of a transdermal patch: The application of transdermal patches is typically within the scope of licensed nursing personnel due to the need for appropriate placement, potential absorption risks, and proper documentation. This task requires understanding of the medication's effects, which is outside the scope of a UAP’s duties.
B) Use of MDIs: Metered-dose inhalers (MDIs) involve medication administration, which requires client assessment, monitoring of technique, and evaluation of response to therapy. These are skills that a UAP is not trained to handle, as they fall within a licensed nurse's responsibilities.
C) Application of a skin barrier cream to the perineal area: UAPs can apply non-medicated skin barrier creams to protect the skin in the perineal area, as it is a basic care activity. This task does not require specialized training in medication administration and is within the typical role of a UAP for maintaining skin integrity.
D) Instillation of eye drops: Administering eye drops involves medication administration, which includes proper technique, dosing, and monitoring for side effects, making it a task for licensed nursing personnel rather than a UAP.
E) Inserting rectal medications: Rectal medication insertion is a more advanced procedure that requires medication administration knowledge, correct positioning, and monitoring, which are responsibilities designated for licensed nursing staff, not a UAP.
F) Instillation of ear drops: Administering ear drops requires an understanding of dosing, technique, and monitoring for adverse effects, all of which are beyond the scope of practice for UAPs and are typically carried out by licensed nursing staff.
G) Inserting vaginal medications: Vaginal medication administration requires understanding of proper technique and monitoring for therapeutic effects or side effects, which necessitates a licensed nurse’s assessment skills and should not be delegated to a UAP.
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.