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. Continuous monitoring of the respiratory status is essential in a child with epiglottitis because the condition can lead to sudden airway obstruction.
B. Suctioning the oropharynx could trigger laryngospasm and worsen airway obstruction.
C. While frequent swallowing may indicate a need for airway assessment, it is not the primary intervention for epiglottitis.
D. Pancreatic enzymes are not relevant for the management of epiglottitis.
Correct Answer is A
Explanation
A. A recent hip arthroplasty puts the client at risk for bleeding if alteplase is administered, as there is a potential for hemorrhage at the surgical site.
B. Acute renal failure may affect medication clearance but is not a contraindication for alteplase.
C. Chronic obstructive pulmonary disease (COPD) does not place the client at risk for alteplase therapy.
D. A family history of malignant hypertension does not directly affect the safety of alteplase therapy.
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