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. PEEP decreases the peak respiratory pressures:
PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.
B. “PEEP increases the number of breaths the patient takes on his own.”:
PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.
C. “PEEP augments the patient’s overall tidal volumes.”:
PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.
D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.
Correct Answer is C
Explanation
A. Transformational leader:
Transformational leaders are characterized by their ability to inspire and motivate followers to achieve exceptional outcomes. They focus on building relationships, fostering creativity, and encouraging individual and team growth. Transformational leaders are often seen as visionary and charismatic.
B. Situational leader:
Situational leadership is a flexible approach where leaders adjust their style based on the situation and the readiness or maturity of their followers. The leader may use different leadership styles, ranging from directing to delegating, depending on the circumstances.
C. Bureaucratic leader:
Bureaucratic leaders strictly enforce rules and regulations. They rely on established policies and procedures to maintain order and control within the organization. This style is often associated with a more structured and rule-based approach to leadership.
D. Laissez-faire leader:
Laissez-faire leaders adopt a hands-off or delegative approach, providing little guidance or direction to their team members. They allow team members a high degree of autonomy and decision-making authority. While this style can promote creativity and independence, it may lead to a lack of structure and accountability in certain situations.
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