A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?
A client who has heart failure and is incontinent of urine
A client who has COPD and dementia and was agitated during the night shift
A client who had a hip arthroplasty 10 days ago and reports pain with ambulation
A client who had a cerebrovascular accident 6 months ago and reports constipation
The Correct Answer is B
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
After a patient dies, postmortem care includes preparing them for family viewing. The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood settling in the face .
The other options are not correct because:
b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.
c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth
d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .
Correct Answer is D
Explanation
d. Pinpoint pupils.
Explanation:
Opioid intoxication is characterized by various signs and symptoms, including central nervous system depression. One common manifestation of opioid intoxication is pinpoint pupils (miosis), which is caused by the effect of opioids on the pupillary constrictor muscles. The pupils become constricted and appear as small dots, hence the term "pinpoint."
The other options are not typical manifestations of opioid intoxication. Tachycardia (rapid heart rate) is more commonly associated with stimulant use rather than opioids. Mental alertness is typically reduced in cases of opioid intoxication, as opioids cause sedation and CNS depression. Hyperreflexia (exaggerated reflexes) is not a typical finding in opioid intoxication; instead, it may occur in withdrawal from certain substances such as alcohol or benzodiazepines.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today