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 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.
Correct Answer is A
Explanation
A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.
B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.
C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.
D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.
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