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 A
Explanation
A. Daily antihistamines can help control itching associated with atopic dermatitis.
B. Solid carbon dioxide is not used to treat atopic dermatitis.
C. Mouth cleansing is not relevant for atopic dermatitis, which primarily affects the skin.
D. Antibiotics are not typically used for atopic dermatitis unless there is a secondary bacterial infection.
Correct Answer is C
Explanation
A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
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