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 "{\"xRanges\":[132,167],\"yRanges\":[113.5,148.5]}"
Explanation
A. This area corresponds to the trachea which produces bronchial breath sounds which are inconsistent with lower airway disease as expected in pneumonia.
B. This area corresponds to the right upper lung lobe which is accurate for auscultation for abnormal breath sounds such as crackles.
C. This area corresponds to the right upper quadrant for auscultation for bowel sounds.
D. This area corresponds to the cardiac region which is more accurate for auscultation of heart sounds.
Correct Answer is ["255"]
Explanation
To calculate:
4,080 mL ÷ 2 = 2,040 mL
2,040 mL ÷ 8 hours = 255 mL/hr.
Thus, the nurse should set the IV infusion pump to deliver 255 mL/hr.
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