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 C
Explanation
A. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.
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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