A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?
A client who is short of breath.
A client who received pain medication 30 min ago.
A client who is to be discharged at 11:00.
A client who is ambulatory and going for an x-ray at 10:00.
The Correct Answer is A
Choice A rationale:
A client who is short of breath is experiencing a life-threatening situation and should be seen first.
Choice B rationale:
A client who received pain medication 30 min ago is likely to be comfortable and can be seen later.
Choice C rationale:
A client who is to be discharged at 11:00 can be seen closer to the discharge time.
Choice D rationale:
A client who is ambulatory and going for an x-ray at 10:00 can be seen after the x-ray.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Metabolic acidosis would likely present with rapid, deep breathing (Kussmaul respirations), not slow and shallow breathing.
Choice B rationale:
The client’s symptoms of vomiting (which can cause a loss of stomach acid), dizziness, palpitations, and numbness and tingling in the extremities and around the mouth are consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis would likely present with rapid breathing, not slow and shallow breathing.
Choice D rationale:
Respiratory acidosis would likely present with rapid, shallow breathing, not slow and shallow breathing.
Correct Answer is B
Explanation
Choice A rationale:
Initiating diuretic therapy is incorrect because it would further decrease the client’s already low calcium level.
Choice B rationale:
Implementing seizure precautions is correct because hypocalcemia can cause neuromuscular irritability and seizures.
Choice C rationale:
Preparing the client for hemodialysis is incorrect because it is not the first-line treatment for hypocalcemia.
Choice D rationale:
Administering phosphate is incorrect because it would further decrease the client’s already low calcium level.
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