A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
A client who has pneumonia and has an axillary temperature of 38° C (101° F)
A client who has diarrhea and requests clear liquids for breakfast
A client who has a cast on the left leg and reports numbness and paresthesia
A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
The Correct Answer is C
Rationale:
A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.
B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.
C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.
D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
Correct Answer is B
Explanation
Rationale:
A. Identifying changes within the family unit can be important but is not the immediate priority for medical stabilization.
B. Gaining weight is a critical goal for clients with anorexia nervosa to address their physical health and nutritional status.
C. Making positive statements about body image is helpful but secondary to the goal of weight gain.
D. Feeling in control of behavior is important for long-term recovery but is not the immediate priority compared to physical health.
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