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 was just given a glass of orange juice for a low blood glucose level.

A client who has 100 mL of fluid remaining in his IV bag.

Answer and Explanation

The Correct Answer is C

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.
The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
Choice B is wrong because a client who received pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.
Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.
Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.

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Correct Answer is A

Explanation

This statement indicates that the client understands the need to avoid activities that can increase intraocular pressure, such as lifting heavy objects, bending over, coughing, or straining. An increase in intraocular pressure can cause complications such as bleeding, inflammation, or recurrent detachment of the retina.

Choice B is wrong because sewing is a near-vision activity that can cause eye strain and fatigue. The client should avoid near-vision activities for at least two weeks after surgery.

Choice C is wrong because jogging is a vigorous exercise that can cause jarring movements and increase blood pressure. The client should avoid vigorous exercise for at least six weeks after surgery.

Choice D is wrong because bending at the waist can increase intraocular pressure and compromise the healing of the retina. The client should avoid bending at the waist for at least two weeks after surgery.

The retina is the light-sensitive layer of tissue that lines the back of the eye.

It converts light into electrical signals that are sent to the brain through the optic nerve.

A detached retina occurs when the retina separates from its underlying tissue due to a tear, hole, or break in the retina.

This can cause vision loss or blindness if not treated promptly.

The most common treatment for a detached retina is a surgery called vitrectomy. It typically involves three main steps:

The vitreous gel inside the eye must be removed.
A gas bubble is injected into the eye to hold the retina against its underlying tissue while allowing it to heal.
Laser or cryotherapy creates scar tissue that helps reattach the retina.

The recovery time after retinal detachment surgery varies depending on the type and extent of the detachment, the type of surgery, and the individual healing process of the client.

Some general guidelines to follow after retinal detachment surgery are:

Rest your eyes for at least two weeks after the surgery.
Wear sunglasses when outdoors, as bright light may cause discomfort and strain on the eye that has been operated upon.
If your doctor recommends, use artificial tears every few hours to keep moisture in the eye and lubricate it correctly.
Take your medicines as directed by your doctor.
You may use ice on your eye to reduce swelling

A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. B. Measure the fundal height to determine the placement of the ultrasound stethoscope. C. Place the client in a side-lying position prior to assessing the fetal heart rate. D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.

Correct Answer is A

Explanation

This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.

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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 providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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