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 C
Explanation
A. Incorrect. Headache can be associated with various conditions, but it is not a specific manifestation of hypovolemia.
B. Incorrect. Shortness of breath can occur in conditions affecting the respiratory system, such as pneumonia or asthma, but it is not a primary manifestation of hypovolemia.
C. Correct. Dizziness is a common manifestation of hypovolemia due to decreased blood volume and inadequate perfusion to the brain.
D. Incorrect. Epistaxis (nosebleed) might not be directly related to hypovolemia. It could be associated with other factors, such as dry air or nasal irritation.
Correct Answer is C
Explanation
Choice C rationale:
Recommending scrambled eggs is appropriate for a client with dysphagia caused by a stroke. Scrambled eggs have a soft and moist texture, making them easier to swallow for individuals with difficulty swallowing. It is crucial to choose foods that are easy to chew and swallow, as well as foods that can be easily moistened with sauces or gravies to aid in swallowing.
Choice A rationale:
Crispy rice bars are dry and hard, posing a significant risk for individuals with dysphagia. Foods that are dry, crunchy, or crumbly can be difficult to swallow and may lead to choking, especially for individuals with impaired swallowing abilities. Therefore, crispy rice bars are not a suitable choice for a client with dysphagia.
Choice B rationale:
Peanut butter, especially when consumed without added moisture or in large amounts, can be thick and sticky, making it challenging to swallow, especially for individuals with dysphagia. It can adhere to the walls of the throat, causing discomfort and difficulty in swallowing. While peanut butter can be a good source of protein, it is not an ideal choice for someone with swallowing difficulties.
Choice D rationale:
Soda crackers are dry and can be crumbly, making them a poor
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