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 A

Explanation

Rationale:

A. Radiologic is correct as a "dirty bomb" (radiological dispersal device) involves the dispersal of radioactive materials.

B. Anthrax is a biological agent, not associated with a dirty bomb.

C. Chemical refers to a chemical weapon, which is not what a dirty bomb involves.

D. Sarin is a nerve agent, not related to the concept of a dirty bomb.

A. Removal of the nasogastric tube of a client who has been receiving enteral feedings B. Monitoring vital signs of a client who had an appendectomy 12 hr ago C. Application of antibiotic ointment to the arm of a client who has dermatitis D. Obtaining medical history information from a stable client who is being admitted

Correct Answer is B

Explanation

Rationale:

A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.

B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.

C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.

D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.

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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

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents?

Correct Answer is A

Explanation

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Correct Answer is B

Explanation

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