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 D

Explanation

Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.

A. Provide the client with written materials using large print. B. Provide a long teaching session. C. Simplify terms using acronyms. D. Ask the client to demonstrate the skill.

Correct Answer is D

Explanation

A. Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.

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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 charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Correct Answer is D

Explanation

A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding?

Correct Answer is D

Explanation

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