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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.

Choice B rationale:

The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.

Choice C rationale:

Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.

Choice D rationale:

Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.

A. Drop prescribed amount of medication into the conjunctival sac. B. Place the eyedropper gently against the sclera. C. Don sterile gloves to instill the medication. D. Gently rub the eye after instilling the medication.

Correct Answer is A

Explanation

Choice A rationale:

The medication should be dropped into the conjunctival sac, which is the space between the lower eyelid and the eyeball. This is the correct method for administering ophthalmic drops.

Choice B rationale:

The eyedropper should not touch any part of the eye, including the sclera, to avoid contamination and potential infection.

Choice C rationale:

It is not necessary to don sterile gloves when administering ophthalmic drops. Clean gloves or hand hygiene is sufficient.

Choice D rationale:

Rubbing the eye after instilling medication can cause irritation and may disperse the medication, reducing its effectiveness.

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A nurse has received change-of-shift report on four clients.Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is preparing to administer timolol ophthalmic drops to a client who has glaucoma.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?