A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Obtain more details of the client's claim of abuse. This is the most appropriate initial action because it prioritizes the client's safety and well-being. By gathering more information about the alleged abuse, the nurse can assess the situation comprehensively before taking further steps. Option A, focusing on reality orientation, is not the most immediate concern when a client discloses abuse. While it is important in certain situations, addressing the abuse claim takes precedence. Option B, assisting with the report to the police, should come after verifying the client's claim to ensure accuracy and appropriateness of involving law enforcement. Option D, documenting the statement on the client's chart, is important but should follow a thorough assessment and investigation of the abuse allegation to ensure proper documentation. Educationally, this question highlights the critical thinking skills needed in nursing practice when faced with sensitive and potentially harmful situations. It emphasizes the importance of assessing and investigating before taking action to ensure the best possible outcome for the client.

Correct Answer: C

Rationale: In the context of nursing delegation principles, the correct answer is option C, assisting the client with ambulation, as it falls within the scope of practice for unlicensed assistive personnel (UAP). UAPs are trained to provide direct client care tasks that do not require nursing judgment or assessment. They can safely assist clients with activities of daily living, such as ambulation, under the supervision of a registered nurse. Option A, assessing the client's ability to ambulate safely, involves a nursing assessment and requires critical thinking skills to determine the client's readiness for ambulation. This task should be performed by a registered nurse. Option B, documenting the client's tolerance of ambulation, involves recording and interpreting client data, which requires nursing judgment and accountability. This task is the responsibility of the nurse to ensure accurate documentation of the client's condition. Option D, evaluating the client's pain level after ambulation, involves assessing the client's response to ambulation and making decisions based on this assessment. This task requires nursing assessment and intervention to address any pain issues effectively. Educationally, understanding the principles of delegation is crucial for nurses to provide safe and efficient care. By knowing which tasks can be delegated to UAPs and which require nursing expertise, nurses can prioritize their responsibilities and ensure that each team member is working within their scope of practice to promote optimal patient outcomes.

Correct Answer: A

Rationale: Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. Positioning and dietary changes can also be part of the care plan, but administering diuretics is the immediate priority.

Correct Answer: A

Rationale: The correct answer is A) Administer 50% dextrose IV push. In this scenario, the client with type 1 diabetes mellitus is experiencing hypoglycemia with symptoms of confusion and sweating, indicating a severe drop in blood sugar levels. The priority action is to rapidly raise the blood sugar to a safe level to prevent further complications such as seizures, coma, or even death. Administering 50% dextrose IV push provides a quick and direct source of glucose to rapidly increase the blood sugar levels. Option B) Provide a carbohydrate snack is not the priority action in this situation because the client is experiencing severe hypoglycemia, and oral intake may not be effective or fast enough to raise the blood sugar levels to a safe range. Option C) Checking the client's urine for ketones is important in managing diabetes, especially type 1, to assess for diabetic ketoacidosis. However, in this acute situation of hypoglycemia, treating the low blood sugar is the immediate priority. Option D) Starting an insulin drip is contraindicated in a client experiencing hypoglycemia as it will further lower the blood sugar levels, worsening the client's condition. Educationally, this scenario highlights the critical importance of recognizing and promptly treating hypoglycemia in clients with diabetes, particularly type 1. Nurses must be able to assess and manage hypoglycemic episodes effectively to prevent serious complications and ensure client safety. Prioritizing actions based on the client's condition and immediate needs is crucial in emergency situations involving clients with diabetes.

Correct Answer: B

Rationale: In this scenario, the nurse's first action should be to discontinue the antibiotic (option B). This is because the client is exhibiting signs of a potential allergic reaction to the medication, as evidenced by the development of a rash and difficulty breathing. Discontinuing the antibiotic is crucial to prevent further adverse reactions and ensure the client's safety. Administering epinephrine (option A) is not appropriate as the client's symptoms do not indicate an anaphylactic reaction that would warrant the use of epinephrine. Assessing the client's oxygen saturation (option C) is important, but in this case, discontinuing the potentially offending medication takes precedence to address the immediate allergic reaction. Calling the healthcare provider (option D) is important, but not the first action to take when the client is experiencing respiratory distress and a rash. Educationally, this question highlights the importance of recognizing and managing allergic reactions to medications promptly in clinical practice. It emphasizes the need for nurses to prioritize patient safety by taking swift and appropriate actions when faced with signs of adverse drug reactions. Understanding the appropriate steps to take in such situations is crucial for providing high-quality patient care.