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 D

Explanation

A. Encourage oral intake of at least 3,000 mL of fluids per day:
This is not a priority intervention for ARDS. While maintaining adequate hydration is important, the primary focus in ARDS is on respiratory support and oxygenation. Excessive fluid intake may exacerbate pulmonary edema in these patients.

B. Offer high-protein and high-carbohydrate foods frequently:
Nutritional support is important in ARDS, but the primary concern is oxygenation and respiratory function. Offering high-protein and high-carbohydrate foods can support the client's overall nutritional needs, but it may not directly address the respiratory distress.

C. Administer low-flow oxygen continuously via nasal cannula:
This is not typically sufficient for ARDS. ARDS often requires higher levels of oxygen support, and low-flow oxygen may not meet the increased oxygen demand. More aggressive oxygenation strategies, such as non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation, may be necessary.

D. Place in a prone position:
Placing the patient in a prone position is a recommended intervention for ARDS. Prone positioning can improve oxygenation by optimizing ventilation-perfusion matching and reducing pressure on the lungs. This intervention is aimed at improving respiratory function in ARDS patients.

A. Reduces inflammation B. Dries mucous membranes C. Stimulates secretions D. Suppresses the urge to cough

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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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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