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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Review the incident of disruptive behavior and discuss the principles of civility and respect.
Unit meeting
Rationale: The incident of disruptive behavior between nurses should be addressed in a unit meeting to foster a culture of respect and teamwork. Discussing this issue with the entire team will help reinforce appropriate behavior and conflict resolution.
Review mandatory nursing skills and competencies for nursing.
Unit meeting
Rationale: Mandatory nursing skills competencies are essential for ensuring that all staff meet the required standards. This should be reviewed during the unit meeting to ensure that all nurses are up to date and compliant with required competencies.
Meet to talk about mislabeling of laboratory specimens and discuss the policy and procedure for how to do it correctly.
Individual Team Member
Rationale: The issue of mislabeling specimens should be addressed directly with the specific individual (TJ, the AP) involved. It’s important to provide corrective feedback and retraining for the individual responsible for the issue.
Review near miss fall and fall precautions, bed position, rounding, and appropriate use of bed or chair alarms.
Unit meeting
Rationale: The near-miss fall incident involves issues that are relevant to the entire unit, such as bed position, use of bed alarms, and rounding practices. Discussing this in a unit meeting can help prevent future incidents by educating all staff on proper procedures.
Review central line infections rates and causes. Include review of proper care of central lines.
Unit meeting
Rationale: Reviewing central line infection rates and proper care is important for the entire team to ensure adherence to best practices and reduce infection rates. This is best addressed in a unit meeting to promote awareness and compliance among all staff.
Correct Answer is D
Explanation
Rationale:
A. WBC 6,000/mm³ is within normal range and does not require follow-up.
B. BUN 15 mg/dL is within normal range and does not require follow-up.
C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.
D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.
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