Difficulty: Medium
Average Score: 87%
Simulated
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.
Correct answer
A, B, E, F
Rationale
After identifying a priority problem, the nurse anticipates a comprehensive plan of care. This includes standard, proactive interventions such as providing education (A), administering prescribed medications (B), applying supplemental oxygen if indicated (E), and gathering essential information like a medication list (F). These are foundational nursing actions. Notifying a provider for intubation (C) is a specific, high-acuity intervention that is only anticipated if assessment data (e.g., severe respiratory distress) directly supports it, which is not specified here. Placing a client in the Trendelenburg position (D) is rarely used and can be dangerous, as it can impair respiratory function and increase intracranial pressure; it is not a standard, anticipatory intervention.