Difficulty: Medium
Average Score: 64%
Simulated
Passage / Scenario
Admission AssessmentHistory
Nurses Notes
Vital Signs
Laboratory Results
Day 1, 1000:
An 88-year-old client was transferred to the ICU after they developed a fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip replacement. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.
The nurse should first plan to perform a____ and then_____ .
Correct answer
B,F
Rationale
[Rationale:
- Reassessing vital signs is crucial to ensure the client's physiological stability and response to interventions.
- Monitoring elimination is important to assess the client's renal and gastrointestinal functions.
Summary:
- Neurological assessment may be important but assessing vital signs takes precedence.
- Administering medication (C) should be based on vital sign reassessment.
- Placing the client in restraints (D) should be a last resort.
- Fall risk assessment (E) is important but not the immediate priority.
- Documenting the client's condition (G) should follow vital sign reassessment and monitoring.]
- Reassessing vital signs is crucial to ensure the client's physiological stability and response to interventions.
- Monitoring elimination is important to assess the client's renal and gastrointestinal functions.
Summary:
- Neurological assessment may be important but assessing vital signs takes precedence.
- Administering medication (C) should be based on vital sign reassessment.
- Placing the client in restraints (D) should be a last resort.
- Fall risk assessment (E) is important but not the immediate priority.
- Documenting the client's condition (G) should follow vital sign reassessment and monitoring.]