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.

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Answer and Explanation

The Correct Answer is C

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

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 a 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 C

Explanation

Tell the client, “You seem to be very upset.”.

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.

Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.

The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.

Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.

Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.

This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.

Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.

Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.

Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.

It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.

Secluding an agitated client may escalate their behavior and violate their rights.

Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.

However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).

A. Provide frequent rest periods for the client. B. Instruct the client to avoid blowing their nose forcefully. C. Assess the client s level of orientation. D. Place the client on a low-carbohydrate diet. E. Restrict the client's sodium intake. F. Advise the client to avoid the use of soap and alcohol-based lotions. G. Place the client under contact isolation.

Correct Answer is ["A","B","C","E","F"]

Explanation

A:Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B:Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D:Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.

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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

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Explanation

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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?