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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. In cases where the client is unable to provide informed consent due to incapacitation, the health care surrogate or legally authorized representative should be involved in the decision-making process.
B. Incorrect. While family support is important, the decision for surgery should primarily be based on medical necessity and the best interests of the client.
C. Incorrect. Determining medical necessity is the responsibility of the medical team, not the nurse.
D. Incorrect. Sending the unsigned informed consent form to the risk manager is not a standard nursing responsibility and does not address the issue of informed consent.
Correct Answer is B
Explanation
A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.
B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.
C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.
D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.