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.

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Correct Answer is C

Explanation

Rationale:

A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.

B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.

C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.

D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.

A. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis. B. The nurse uses clean gloves when discontinuing a client's intravenous infusion. C. The nurse uses the client's telephone number as one form of identification when administering medications to a client. D. The nurse empties a client's drainable colostomy pouch when it is one-third full.

Correct Answer is A

Explanation

Rationale:

A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.

B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.

C.The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).

D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.

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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?

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Naxlex Comprehensive Predictor Exams

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