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.

Answer and Explanation

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

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Correct Answer is A

Explanation

This is the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.

It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.

This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.

Choice C. Explain the purpose of the medication.

This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.

Choice D. Encourage the client to take the medication.

This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.

A. Decreased flexibility. B. Pain when standing. C. Swelling of the ankles. D. Urinary incontinence.

Correct Answer is A

Explanation

Decreased flexibility is a normal age- related change that occurs in the elderly due to loss of elasticity in the ligaments and tendons.
Some possible explanations for the other choices are:
Choice B. Pain when standing. Pain when standing is not a normal finding and could indicate arthritis, osteoporosis, or injury.
Choice C. Swelling of the ankles. Swelling of the ankles is not a normal finding and could indicate heart failure, kidney disease, or venous insufficiency.
Choice D. Urinary incontinence. Urinary incontinence is not a normal finding and could indicate urinary tract infection, prostate enlargement, or neurological impairment.

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A nurse has received report on four clients. What client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client says to the nurse “I will not take the prescribed medication today.” What should be the initial action by the nurse?

Correct Answer is A

Explanation

Which assessment finding would be considered normal in an elderly client?

Correct Answer is A

Explanation

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