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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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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.
Choice B reason:
"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.
Choice C reason:
"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.
Choice D reason:
"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.
It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.
Correct Answer is A
Explanation
The correct answer is A. Increase dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.
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