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
Explanation
Rationale:
A. Respite care provides temporary relief for primary caregivers, giving them time to complete personal tasks or take a break from caregiving responsibilities.
B. Restorative care focuses on improving a client’s ability to perform daily activities and is not specifically aimed at providing caregiver relief.
C. Hospice care is for end-of-life care and is not applicable to the situation described.
D. Mental health care may be necessary if the caregiver is experiencing emotional or psychological stress, but the immediate need described is for respite from caregiving duties.
Correct Answer is B
Explanation
Rationale:
A. Teaching about low-sodium foods requires specialized knowledge and should be performed by an RN.
B. Measuring and recording intake and output can be done by an AP, as it involves routine data collection rather than clinical judgment.
C. Wound irrigation is a more complex procedure that requires clinical skills and should be performed by an RN or LPN.
D. Evaluating pain relief involves clinical assessment and judgment, which is beyond the scope of an AP.
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