Try Naxlex NCLEX-RN (Free-Trial)

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 is scheduled for a procedure in 1 hr

A client who received a pain medication 30 min ago for postoperative pain

A client who has 100 mL of fluid remaining in his IV bag

A client who was just given a glass of orange juice for a low blood glucose level

Answer and Explanation

The Correct Answer is D

A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Incorrect. Restraints should be removed and repositioned, and the client's needs assessed at a frequency that follows institutional policies, which might not always be every 4 hours.

B. Incorrect. Restraints should be attached to the bed frame, not the side rails, to minimize the risk of injury.

C. Incorrect. PRN (as needed) restraint prescriptions should be avoided. Restraints should only be used based on specific criteria and under the guidance of a healthcare provider.

D. Correct. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.

A. The nurse should use a filter needle to withdraw the medication. B. The nurse should use the same needle to draw up and inject the client. C. The nurse should break the neck of the ampule toward their body. D. The nurse should dispose of the ampule in the trash can.

Correct Answer is A

Explanation

A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is D

Explanation

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect?

A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?