A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?
A client who has dementia and is experiencing paranoia
A client who has a UTI and reports itching after receiving a dose of cefaclor PO
A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr
A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III
The Correct Answer is B
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
Correct Answer is D,C,A,B
Explanation
Rationale
- Situation: The client has COPD and is experiencing an acute exacerbation.
- Background: The client has a history of COPD and has been experiencing increasing shortness of breath.
- Assessment: The client's temperature is 39.5°C (103.1°F) and is experiencing shortness of breath.
- Recommendation: Contact the client's provider for a prescription for a sputum culture.
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