A nurse has received report on four clients. What client should the nurse see first?
A client with a fasting blood sugar of 187.
A client with expiratory wheezing after an albuterol treatment.
A client who has been called to surgery 2 hours early.
A client with a blood pressure of 178/90 and needs a dose of atenolol.
The Correct Answer is B
A client with expiratory wheezing after an albuterol treatment.
This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.
The client needs immediate intervention to improve airway patency and oxygenation.
Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.
The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.
Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.
The client can wait until the nurse has assessed the other clients.
Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.
The client needs a dose of atenolol, which is a beta
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the appropriate action because it prevents the spread of infection and maintains a clean environment.
The nurse should also wear gloves and dispose of the bag properly.
Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.
Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.
Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.
Correct Answer is D
Explanation
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
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