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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.

B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.

C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.

D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.

A. A client who is taking a thiazide diuretic B. A client who is vomiting C. A client who has diarrhea D. A client who is having an acute anxiety attack

Correct Answer is C

Explanation

A. A client who is taking a thiazide diuretic:
Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.

B. A client who is vomiting:
Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.

C. A client who has diarrhea.
Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.

D. A client who is having an acute anxiety attack:
Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.

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A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

Correct Answer is C

Explanation

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that a clients is at risk for metabolic acidosis?

Correct Answer is C

Explanation

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

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