A new nurse is having a difficult time identifying which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first?

Hypotension, tachycardia, and lethargy

Dizziness with headache 7/10 on numeric scale

Abdominal pain, hypertensive, and constipated

Febrile, tachycardia, and vomiting

Answer and Explanation

The Correct Answer is A

Choice A reason:

Hypotension (low blood pressure), tachycardia (rapid heart rate), and lethargy are critical symptoms that can indicate a life-threatening condition such as shock or severe dehydration. Hypotension can lead to inadequate perfusion of vital organs, resulting in multi-organ failure if not promptly addressed1. Tachycardia is often a compensatory mechanism for hypotension, and lethargy indicates decreased cerebral perfusion. Immediate intervention is required to stabilize the patient’s condition and prevent further deterioration.

Choice B reason:

Dizziness with a headache rated 7/10 on the numeric scale is concerning but not immediately life-threatening. These symptoms could indicate a variety of conditions, such as migraine, vertigo, or even a mild concussion. While the patient should be assessed and treated, they do not present the same immediate risk as hypotension and tachycardia.

Choice C reason:

Abdominal pain, hypertension (high blood pressure), and constipation are symptoms that need medical attention but are not immediately life-threatening. Hypertension can lead to serious complications if left untreated, but it does not require the same urgent intervention as hypotension. Abdominal pain and constipation, while uncomfortable and potentially indicative of underlying issues, do not pose an immediate threat to life.

Choice D reason:

Febrile (fever), tachycardia, and vomiting are symptoms that suggest an infection or other acute illness. While these symptoms are concerning and need prompt evaluation, they do not pose the same immediate risk as hypotension and tachycardia. Fever and vomiting can lead to dehydration, but this typically develops over a longer period compared to the rapid deterioration seen with hypotension.

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Correct Answer is ["B"]

Explanation

Choice A Reason:

I sleep at least 8 hours each night.

This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.

Choice B Reason:

I cannot seem to quench my thirst.

This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.

Choice C Reason:

I have to void nearly every hour.

Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.

Choice D Reason:

At times my vision is blurry.

Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.

Choice E Reason:

I have lost 10 pounds without even trying.

Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.

A. Adherence to proper hand hygiene B. Suction the client at least every 2 hours C. Administering antiulcer medication D. Providing oral care per protocol E. Elevating the head of the bed F. Suctioning the client on a regular schedule G. Turning and positioning the client at least every 2 hours

Correct Answer is ["A","C","D","E","G"]

Explanation

Choice A Reason: Adherence to proper hand hygiene

Proper hand hygiene is a fundamental practice in preventing infections, including ventilator-associated pneumonia (VAP). Hand hygiene involves washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact, after touching potentially contaminated surfaces, and before performing any aseptic procedures. This practice helps to reduce the transmission of pathogens that can cause infections in mechanically ventilated patients. Studies have shown that adherence to hand hygiene protocols significantly decreases the incidence of VAP and other healthcare-associated infections.

Choice B Reason: Suction the client at least every 2 hours

While suctioning is an important aspect of care for mechanically ventilated patients, routine suctioning every 2 hours is not recommended. Instead, suctioning should be performed based on the patient’s clinical condition and as needed. Over-suctioning can cause trauma to the airway and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice C Reason: Administering antiulcer medication

Administering antiulcer medication is a recommended practice to prevent stress ulcers and gastrointestinal bleeding in mechanically ventilated patients. Stress ulcers can lead to complications such as aspiration of gastric contents, which can contribute to the development of VAP. Antiulcer medications, such as proton pump inhibitors or H2 receptor antagonists, help to reduce gastric acidity and the risk of ulcer formation. This practice is part of the comprehensive care plan to prevent VAP.

Choice D Reason: Providing oral care per protocol

Providing oral care per protocol is a critical component of VAP prevention. Oral care involves cleaning the patient’s mouth, teeth, and gums to reduce the colonization of harmful bacteria that can be aspirated into the lungs. Protocols for oral care typically include the use of antiseptic solutions, such as chlorhexidine, to disinfect the oral cavity. Regular oral care has been shown to significantly reduce the incidence of VAP in mechanically ventilated patients.

Choice E Reason: Elevating the head of the bed

Elevating the head of the bed to an angle of 30 to 45 degrees is a recommended practice to prevent VAP. This position helps to reduce the risk of aspiration of gastric contents into the lungs, which is a major risk factor for VAP. Elevating the head of the bed also promotes better lung expansion and ventilation, which can improve the patient’s respiratory status. This practice is widely recognized as an effective measure to prevent VAP.

Choice F Reason: Suctioning the client on a regular schedule

Similar to Choice B, routine suctioning on a regular schedule is not recommended. Suctioning should be performed based on the patient’s clinical needs and not on a fixed schedule. Over-suctioning can cause harm and increase the risk of infection. Therefore, this choice is not included in the best practices for preventing VAP.

Choice G Reason: Turning and positioning the client at least every 2 hours

Turning and positioning the client at least every 2 hours is an important practice to prevent complications such as pressure ulcers and to promote lung expansion. Regular repositioning helps to improve ventilation and drainage of secretions, reducing the risk of VAP. This practice is part of the standard care for mechanically ventilated patients to prevent various complications, including VAP.

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A new nurse is having a difficult time identifying which client should be seen first because they all seem important. The nurse preceptor helps and explains that the client with which of the following should be seen first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a routine medical evaluation, a client is found to have a random blood glucose level of 310 mg/dL. Which client statements are concerning to the nurse? Select all that apply.

Correct Answer is ["B"]

Explanation

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply)

Correct Answer is ["A","C","D","E","G"]

Explanation

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