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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.
Choice B rationale:
Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.
Choice C rationale:
Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.
Correct Answer is C
Explanation
This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can. This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.
Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.
Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.
Choice D is wrong because recording the average of the readings is not recommended.
You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.
Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these
factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.
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