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":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
A. Start an IV bolus of lactated Ringer's solution: Not Indicated
- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.
B. Stay with the client for the first 15 min of the transfusion: Not Indicated
- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.
C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated
- There is no indication of a need for a blood transfusion in the client's assessment findings.
D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.
E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.
Correct Answer is ["B","D","E"]
Explanation
The nurse should discuss the following dietary recommendations with the client who has Crohn's disease:
Avoid eating fried, fatty foods and large meals: Fried and fatty foods can be difficult to digest and may worsen symptoms of diarrhea and abdominal pain. Consuming large meals can also put additional strain on the digestive system.
Limit high fiber foods, such as beans, popcorn, and seeds: High fiber foods can be challenging to digest and may exacerbate symptoms of Crohn's disease. Limiting these foods can help reduce gastrointestinal irritation and promote symptom relief.
Take a vitamin supplement daily with a meal: Crohn's disease can lead to nutrient deficiencies due to malabsorption. Taking a daily vitamin supplement with a meal can help ensure that the client receives essential nutrients and maintain overall nutritional status.
The following options are not appropriate dietary recommendations for a client with Crohn's disease:
- Drinking dairy and effervescent sodas for hydration: Dairy products can trigger symptoms in some individuals with Crohn's disease, especially if they have lactose intolerance. Effervescent sodas may contain carbonation and artificial sweeteners that can aggravate symptoms. Encouraging non-dairy sources of hydration, such as water or herbal teas, would be more appropriate.
- Enjoying fast food restaurants only if dining with friends: Fast food options are generally high in fat, sodium, and other additives that may worsen symptoms in individuals with Crohn's disease. It is advisable to limit or avoid fast food consumption altogether, regardless of whether dining alone or with others.
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