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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Coughing while swallowing food can help clear the airway but is not a primary technique for managing dysphagia.
B. Tilting the head forward when swallowing helps to close the airway and reduce the risk of aspiration, indicating effective teaching.
C. Food should be placed on the stronger side of the mouth to aid in effective chewing and swallowing.
D. A 30° angle is insufficient; the client should be in an upright position (90°) to reduce the risk of aspiration.
Correct Answer is C
Explanation
A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.
B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.
C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.
D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.
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