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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

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Correct Answer is D

Explanation

A. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Reverse Trendelenburg involves tilting the bed so that the head is elevated and the feet are lower. While this position may help with respiratory difficulties (by allowing the diaphragm to expand), it does not address the concern of aortocaval compression, which is critical during pregnancy.
C. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. The wedge position helps maintain blood flow to the placenta by relieving aortocaval compression, thereby improving venous return and placental perfusion. This is particularly important in pregnant clients, where the uterus can exert significant pressure on these blood vessels in the supine position.

A. Rinse the catheter to remove secretions. B. Don sterile gloves. C. Apply suction while rotating the catheter. D. Insert the catheter during the client's inspiration. E. Turn on the suction and set the pressure.

Correct Answer is E, B, D,C,A

Explanation

2. E. Turn on the suction and set the pressure.

1. B. Don sterile gloves.

3. D. Insert the catheter during the client's inspiration.

4. C. Apply suction while rotating the catheter.

5. A. Rinse the catheter to remove secretions.

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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 is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E, B, D,C,A

Explanation

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