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

Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.

A. Check the patency of the client's airway. B. Determine the poison that was ingested. C. Position the client side-lying D. Identify the amount of poison that was ingested.

Correct Answer is A

Explanation

A. Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
B. Determining the poison is important but not the immediate priority during a seizure.
C. Positioning the client side-lying is important to prevent aspiration, but the first action should be to ensure the airway is clear.
D. Identifying the amount of poison ingested is important for treatment but not the immediate priority during a seizure.

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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

A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Correct Answer is A

Explanation

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