A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
A client who was administered acyclovir for cellulitis reports pain in the affected leg
A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache
A client who was administered erythromycin for acute glomerulonephritis and reports reddish brown urinary output
A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dl
The Correct Answer is D
A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.
B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.
C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.
D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “I understand your fears, I was a smoker also.”
While sharing personal experiences can sometimes be relatable, it may not be the most therapeutic response in this situation. The focus should be on the client's feelings and concerns rather than the nurse's personal history.
B. “Don’t worry. The important thing is you have now quit smoking.”
Dismissing the client's fear with a "don't worry" statement may invalidate the client's emotions. It's important to acknowledge and address the client's feelings rather than downplaying them.
C. “Your doctor is a great surgeon. You will be fine.”
While it's positive to express confidence in the medical team, this response does not directly address the client's emotional concerns. The client's fear may extend beyond the surgical aspect, and it's essential to explore and discuss those fears.
D. “It’s okay to feel scared. Let’s talk about what you are afraid of.”
This response is the most therapeutic as it acknowledges the client's emotions, validates the fear, and opens the door for further communication. It invites the client to express her concerns and allows the nurse to provide support and information based on the client's specific fears.
Correct Answer is C
Explanation
A. Reduces inflammation:
This action is more characteristic of anti-inflammatory medications, such as corticosteroids. Expectorants, however, do not primarily reduce inflammation.
B. Dries mucous membranes:
This action is more characteristic of antihistamines or decongestants, which may help reduce nasal congestion by drying mucous membranes. Expectorants have the opposite effect; they promote the thinning of mucus.
C. Stimulates secretions
An expectorant is a type of medication that works by promoting the clearance of mucus from the respiratory tract. It does so by thinning and loosening mucus, making it easier for the patient to cough up and expel. Expectorants help in facilitating the removal of excessive mucus and can be useful in conditions where there is a productive cough associated with excessive mucus production.
D. Suppresses the urge to cough:
This action is associated with antitussive medications, which are cough suppressants. Expectorants, on the other hand, stimulate the removal of mucus and do not suppress the urge to cough
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