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 B
Explanation
A. Offering clear liquids should typically occur 6 hours or later postoperatively; in the first few hours, the focus is on monitoring and pain management.
B. Administering analgesics on a scheduled basis ensures consistent pain control and helps prevent unnecessary discomfort.
C. Applying a warm compress is not appropriate in the early postoperative period and may risk increased bleeding.
D. Giving cromolyn nebulized solution is unrelated to appendectomy recovery and is not part of standard postoperative care.
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.
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