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 D
Explanation
A. Maternal hypoglycemia typically does not cause fetal bradycardia.
B. Chorioamnionitis could lead to fetal tachycardia, not bradycardia.
C. Maternal fever may cause fetal tachycardia, not bradycardia.
D. Fetal anemia can lead to fetal bradycardia as the fetus struggles to maintain adequate oxygenation.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.
Rationale
First Anticipated Step: Obtain IV Access:
In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood
products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.
Second Anticipated Step:
Prepare to administer IV fluids:
The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.
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