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

Answer and Explanation

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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Correct Answer is A

Explanation

A. A licensed practical nurse (LPN) is capable of performing sterile dressing changes, which is within their scope of practice.
B. An admission assessment requires a registered nurse (RN) to evaluate and formulate a comprehensive care plan, which exceeds the scope of an LPN.
C. Discharge teaching requires the RN’s expertise to provide in-depth education and ensure the patient understands the plan.
D. Completing the Glasgow Coma Scale requires an RN to assess neurological status and make appropriate decisions about care.

A. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site. B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site. C. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site. D. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.

Correct Answer is B

Explanation

A. Applying intermittent pressure may not effectively stop bleeding from a cardiac catheterization site, as continuous pressure is typically more effective in controlling post-procedural bleeding.
B. Applying continuous pressure 2.5 cm above the percutaneous site is the appropriate action to stop bleeding from the catheterization site.
C. Applying pressure below the site may not effectively control bleeding and could compromise the site.
D. Continuous pressure should be applied above the percutaneous site, not below, to control bleeding.

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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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