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 C
Explanation
Administer sublingual nitroglycerin.
Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.
Choice A is wrong because checking a STAT cardiac troponin is not the first priority.
Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.
Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.
Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.
They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.
Choice D is wrong because administering oxygen is not the first priority.
Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.
Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.
If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.
Correct Answer is A
Explanation
This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.
The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.
Choice B is wrong because Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.
The AP did not actually touch the client or carry out the threat, so there was no battery.
Choice C is wrong because Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.
The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.
Choice D is wrong because Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.
The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.
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