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 B
Explanation
The correct answer is choice B. Using an electronic messaging system to remind clients when to take medications. Tertiary prevention in healthcare involves measures taken to reduce the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life, and their life expectancy. In the context of an HIV clinic, reminding clients to take their medications can help manage the disease effectively and prevent complications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is incorrect because this is more aligned with primary prevention, which aims to prevent the onset of an illness or injury before the disease process begins.
Choice C rationale:
Providing clients with information about the benefits of exercise is incorrect as this is generally considered a part of primary prevention, promoting general health to prevent various diseases.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is incorrect because this is typically associated with secondary prevention, which involves screening to identify diseases in the earliest stages.
Correct Answer is A
Explanation
Choice A reason:
Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.
Choice B reason:
Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.
Choice C reason:
Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.
Choice D reason:
Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.
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