The nurse is caring for a homeless client admitted three days ago for frostbite. The nurse notes in the client's record that he has a history of alcohol abuse. The nurse's priority is:
a. assess the client's wound dressings for drainage.
b. monitor the client's vital signs every two hours
c. place the client on a cardiorespiratory monitor.
d. prepare to protect the client from harm during delirium tremors.
ANS: D
Feedback
A Incorrect: Although an important assessment, this is not the nurse's priority.
B Incorrect: This is not an appropriate nursing action for this client.
C Incorrect: This is not a necessary nursing action for this client.
D Correct: At 72 hours following cessation of alcohol in a client with a history of alcohol abuse, the nurse's priority is to anticipate the client will experience DTs and to protect the client from harm.
You might also like to view...
A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. The nurse explains that if untreated, this condition could result in:
a. a large for gestational age infant. b. anorexia nervosa. c. preterm delivery. d. maternal or fetal death.
The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in her arms and legs. The nurse would attribute this loss to changes in which process?
The nurse notices that a patient in the intensive care unit has lost muscle mass and tone in her arms and legs. The nurse would attribute this loss to changes in which process?
An important nursing intervention when caring for a child who is experiencing a seizure would be to:
a. describe and record the seizure activity observed. b. restrain the child when seizure occurs to prevent bodily harm. c. place a tongue blade between the teeth if they become clenched. d. suction the child during a seizure to prevent aspiration.
Which of the following is not considered a core competency for nurses caring for older adults?
a) Analyze the impact of an aging society on the health care system b) Obtain certification in gerontological nursing c) Prevent or reduce common risk factors that contribute to functional decline d) Recognize one's own attitudes about aging