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 B

Explanation

The correct answer is choice b. Remove the device from the room.

Choice A rationale:

Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.

Choice B rationale:

Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.

Choice C rationale:

Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.

Choice D rationale:

Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.

A. Decrease insoluble fiber intake. B. Increase exercise. C. Reduce water intake D. take a laxative every day

Correct Answer is B

Explanation

Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.

Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.

Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.

Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.

Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.

Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.

Laxatives should be used only as a last resort and under the guidance of a health care provider.

Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

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

While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

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