A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who received a pain medication 30 min ago for postoperative pain
A client who was just given a glass of orange juice for a low blood glucose level
A client who has 100 mL of fluid remaining in his IV bag
A client who is scheduled for a procedure in 1 hr
The Correct Answer is B
A. A client who has recently received pain medication should be assessed for effectiveness but is not in immediate danger.
B. A client who received orange juice for a low blood glucose level needs to be assessed for a return to normal glucose levels as hypoglycemia is a priority concern.
C. A client with 100 mL of fluid remaining in the IV bag can wait for assessment as their fluid needs can be managed once the infusion is complete.
D. A client scheduled for a procedure in 1 hour is important to assess, but their immediate clinical needs may be less critical than a client with hypoglycemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Frequent nosebleeds are not typically associated with coarctation of the aorta.
B. Upper extremity hypotension is unlikely; the condition usually leads to higher blood pressure in the upper extremities.
C. Increased intracranial pressure is not a direct result of coarctation of the aorta.
D. Weak femoral pulses are a common finding due to the narrowing of the aorta, which limits blood flow to the lower extremities.
Correct Answer is B
Explanation
A. Elevated fasting blood glucose is a concern but does not immediately contraindicate clozapine administration. It can be monitored and managed.
B. Clozapine can cause agranulocytosis, and a low absolute neutrophil count (ANC) is a contraindication for the medication. The threshold for stopping clozapine is typically an ANC of less than 1,500/mm3.
C. A heart rate of 58/min is not a contraindication for clozapine. It may require monitoring but is not necessarily concerning.
D. An Hgb level of 12.5 g/dL is within the normal range and does not contraindicate the use of clozapine.
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