Author Question: A client has been using the call light routinely throughout the evening. Upon entering the room, the ... (Read 45 times)

mp14 · **on:** Jul 23, 2018

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority).

1. Family is at bedside.
2. The IV pump is running on battery.
3. ECG monitor shows tachycardia.
4. Client reports being restless.
5. O2 tubing is not attached to wall regulator.

Question 2

A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client's past records.

The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The client says, Why don't you people talk to each other and quit asking the same things over and over? The best response of the nurse is:
1. In order to make sure all of your information is complete, I need to ask these questions.
2. You're right. Let me know if there's anything you need right now.
3. I'll be done shortly, just give me a few more minutes.
4. You shouldn't be upset. We're only doing our jobs.

zenzy · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3,4,5,2,1
Rationale 1: Has no apparent bearing on client's symptoms
Rationale 2: Indicates an issue worth observing
Rationale 3: Indicates a objective cardiac symptom
Rationale 4: Indicates a subjective symptom
Rationale 5: Indicates a possible cause of client's symptoms

Answer to Question 2

Correct Answer: 2
Rationale 1: Before asking more questions, the nurse should review what is already at hand.
Rationale 2: Repeated questioning can be stressful and annoying, especially for hospitalized clients, and cause concern about the lack of communication among health professionals. The nurse should review previous records that contain data about the client's occupation, religion, and marital status, as well as take time to review all the information the previous nurse collected. Validating the client's feelings is always a good idea and helps to build rapport between the nurse and client. response.
Rationale 3: This option does not address the client's legitimate concern nor acknowledge the client's feelings.
Rationale 4: Telling the client we're only doing our jobs is belittling to the client and doesn't offer any therapeutic response.