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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 B

Explanation

A. Incorrect. Suggesting finding alternative remedies through an online support group may not provide accurate or safe information.
B. Correct. This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.
C. Incorrect. While it's important to respect the client's personal beliefs, the nurse should also ensure that the chosen therapies are safe and effective.
D. Incorrect. Waiting for the provider to suggest alternative therapies may delay the client's access to safe and effective treatments.

A. Moving both crutches with the stronger leg forward first B. Stepping with his affected leg first when going up stairs C. Positioning both hands on the grips with his elbows slightly flexed D. Supporting his body weight while leaning on the axillary crutch pads

Correct Answer is C

Explanation

The correct answer is a. Moving both crutches with the stronger leg forward first.

Rationale for Choice C:

Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.

Rationale for Other Choices:

a.In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.

b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.

d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.

Additional Information:

Practice and supervision:It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
Gradual progression:The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
Pain management:Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.

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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?

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