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 C
Explanation
Choice A rationale:
Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3, which is not the case here.
Choice B rationale:
Respiratory acidosis is incorrect because it would present with a low pH and high PaCO2, which is not the case here.
Choice C rationale:
Metabolic acidosis is correct because it presents with a low pH and low HCO3, which matches the client’s ABG results.
Choice D rationale:
Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2, which is not the case here.
Correct Answer is B
Explanation
Choice A rationale:
Low blood pressure (BP) is a symptom of hypovolemic shock due to decreased blood volume, but the pulse rate typically increases as the body tries to compensate for the low BP, not decrease.
Choice B rationale:
Hypovolemic shock is characterized by low BP due to loss of blood or fluid volume and a high pulse rate as the body tries to compensate for the decreased blood flow.
Choice C rationale:
High BP is not typically associated with hypovolemic shock. Instead, BP is usually low due to decreased blood volume.
Choice D rationale:
High BP is not typically a symptom of hypovolemic shock. While the pulse rate may be high as the body tries to compensate for low blood volume, the BP is usually low.
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