A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode

A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800

A client who was admitted for chest pain and is reporting a new onset of indigestion

A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400

Answer and Explanation

The Correct Answer is C

A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.

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Correct Answer is C

Explanation

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

A. Skin color B. Temperature C. Fluid intake D. Hemoglobin level

Correct Answer is B

Explanation

A. Skin color is not the most critical parameter before a blood transfusion.
B. Temperature is important to monitor for baseline and the temperature should be monitored during infusion since an increase in temperature can indicate a transfusion reaction.
C. Fluid intake is relevant to assess overall hydration status but not the most critical before the transfusion.
D. Hemoglobin level is crucial to determine but it is not the most important data to obtain immediately before the infusion, as it does not change rapidly during the transfusion and does not indicate an ongoing reaction.

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A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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