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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a high PaCO2 and a low pH. The client’s ABG results do not match this pattern.
Choice B rationale:
Metabolic acidosis is characterized by a low HCO3 and a low pH. The client’s ABG results do not match this pattern.
Choice C rationale:
Respiratory alkalosis is characterized by a low PaCO2 and a high pH. The client’s ABG results do not match this pattern.
Choice D rationale:
Metabolic alkalosis is characterized by a high HCO3 and a high pH. The client’s ABG results match this pattern. Normal values for pH, PaCO2, and HCO3 are 7.35-7.45, 35-45 mm Hg, and 22-26 mEq/L respectively.
Correct Answer is B
Explanation
Choice A rationale:
The list obtained from the client should include all medications the client is taking, regardless of who prescribed them. This includes over-the-counter medications and supplements.
Choice B rationale:
Providing a comprehensive list of medications for the client at the time of discharge is an important component of medication reconciliation. This helps to ensure the client understands what medications they should be taking, how to take them, and why they are taking them.
Choice C rationale:
The reconciliation process should be completed at each transition of care, not just when the client is first admitted to the hospital. This is to ensure that any changes in medication are accurately documented and communicated.
Choice D rationale:
A nurse should not write a verbal order in the medical record for medications the client was taking at home without confirmation from the provider. This could lead to errors in medication administration.
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