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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measuring gastric residual volumes every 4 hours is important to assess the client’s tolerance to the feeding and prevent aspiration.
B. Flushing with saline should only be done as necessary for medication administration and not routinely unless specified by protocol.
C. The rate of feeding should be adjusted based on the client’s tolerance and not increased arbitrarily.
D. The head of the bed should be maintained at 30–45° to reduce the risk of aspiration.
Correct Answer is A
Explanation
A. The primary concern after an overdose of valsartan is hypotension, as it can cause significant blood pressure lowering.
B. Monitoring urine output is important but not the priority immediately after an overdose.
C. Laboratory results are useful but not critical in this immediate situation.
D. Nasal congestion is a possible side effect of valsartan but is not as urgent as monitoring for hypotension.
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