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:
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.
Correct Answer is B
Explanation
Choice A rationale:
Discarding any partial doses found in the cabinet in the sharps container is not the correct procedure. Partial doses should be wasted in the presence of another nurse.
Choice B rationale:
Verifying that the amounts of each medication counted match the amounts on the inventory record is the correct procedure. This ensures accurate accounting of controlled substances.
Choice C rationale:
Setting aside any controlled substances the nurse plans to give during her shift is not the correct procedure. Medications should be removed from the secure cabinet as needed.
Choice D rationale:
Co-signing any notations of wasting controlled substances on the previous shift is not the correct procedure. Wasting should be witnessed and co-signed at the time it occurs.
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