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

Answer and Explanation

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

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Correct Answer is C

Explanation

Rationale:

A. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.

B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.

C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.

D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.

A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight B. A client who has terminal cancer and needs assistance with pain management C. A client who has dementia and needs help with activities of daily living D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work

Correct Answer is B

Explanation

Rationale:

A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eyesight may need home health services but not necessarily hospice care unless they are terminally ill.

B. A client who has terminal cancer and needs assistance with pain management is appropriate for hospice care, which focuses on comfort and end-of-life care.

C. A client who has dementia and needs help with activities of daily living might benefit from long-term care or home care services but not necessarily hospice unless they are in the terminal stages.

D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work requires supportive care rather than hospice care.

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A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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