Setting Priorities When Caring for Clients leadership questions

After receiving the shift report, the 7:00 P.M. to 7:00 A.M. nurse is reviewing the medication administration record (MAR) of the client diagnosed with type 2 diabetes. Which intervention should the nurse implement? 1. Make sure the client receives a snack at bedtime. 2. Check the client's blood glucose level immediately. 3. Have the UAP give the client some orange juice. 4. Teach the client about the symptoms of diabetic ketoacidosis.

1. The client received an intermediate acting insulin at 1630 plus the sliding scale insulin dose to lower the client's blood glucose level. This client should receive a bedtime snack to make sure the client does not experience a hypoglycemic reaction during the night. Intermediate insulin generally peaks 6 to 8 hours after administration, 2230 to 0030 for this client.

The nurse is caring for clients on a medical unit. Which laboratory data warrants immediate intervention by the nurse? 1. The PTT of 98 seconds with a control of 36 on a client diagnosed with deep vein thrombosis (DVT). 2. The hemoglobin and hematocrit (H&H) of 10.4/31 for a client diagnosed with a bleeding gastric ulcer. 3. The white blood cell (WBC) count of 4800 for a client diagnosed with leukemia. 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN).

1. Therapeutic levels for PTT should be 1-1/2 to 2 times the control—that is, 54 to 72 seconds when the control is 36; therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the facility protocol.

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with pneumonia who has bilateral crackles. 2. The client on strict bed rest who is complaining of calf pain. 3. The client who complains of low back pain when sitting in a chair. 4. The client who is upset because the food is cold all the time.

2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should be assessed first.

The nurse is caring for clients on a medical unit. Which intervention should the nurse implement first? 1. Change the leg wound dressing for a client who has ambulated in the hall. 2. Discuss the correct method of obtaining a blood glucose level with the unlicensed assistive personnel (UAP). 3. Check on the male client who called the desk to say he has just vomited. 4. Place a call to the extended care facility to give the report on a discharged client.

3. This client has experienced a physiologic problem, and the nurse must assess the client and the emesis to decide on possible interventions.

The 7:00 P.M. to 7:00 A.M. nurse has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The male client who has just been brought to the floor from the emergency department (ED) with no report of complaints. 2. The female client who received pain medication 30 minutes ago for pain that was a level "8" on a 1-to-10 pain scale. 3. The male client who had a cardiac catheterization in the morning and has been allowed to use the bathroom one time. 4. The female client who has been turning on the call light frequently and stating that her care has been neglected.

1. This client may or may not be stable. He may have "no complaints" at this time, but the nurse must assess this client first to determine that whatever the complaint was that brought him to the ED has stabilized. This client should be seen first.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

4. The therapeutic range for Dilantin is 10-20 mg/dL. This client's higher level warrants intervention because the serum level is above therapeutic range.

The client diagnosed with breast cancer who is positive for the BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse's best response? 1. "If it were me in this situation, I would consider having a bilateral mastectomy." 2. "What treatment options has your health-care provider (HCP) discussed with you?" 3. "You should discuss your treatment options with your HCP." 4. "Have you talked with your significant other about the treatment options available to you?"

2. The nurse must assess what information the client actually needs. To do this, the nurse must know what treatment options have been suggested to the client. Assessment is the first step in the nursing process.

The nurse is administering medications for clients on a medical unit. Which medication should the nurse administer first? 1. The narcotic pain medication to a client complaining that his pain is an "8." 2. A loop diuretic to a client diagnosed with heart failure who has 3 pitting edema. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

3. Anticholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. This is the priority medication.

The nurse is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The intravenous (IV) proton-pump inhibitor medication to a client who is to be given nothing by mouth (NPO). 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. 3. The rapid-acting insulin Humalog to a client who has the breakfast tray in the room. 4. The stimulant laxative to a client who has not had a bowel movement in 3 days.

3. Rapid-acting insulin, such as Humalog, peaks in 15 to 20 minutes and should be administered when or immediately before the client eats the food on the tray; therefore, this medication should be administered first.

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus (upper gastrointestinal [GI] system). Which intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fluid intake after the procedure. 3. Explain that the client will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure.

4. The test is a barium study of the upper GI system and requires the client's upper GI system to be empty. This client should be made NPO at least 8 to 10 hours before the test.