How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

A.

Tachycardia

B.

Cramping

C.

Seizures

D.

Elevated temperature

Answer and Explanation

The Correct Answer is C

Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.

Correct Answer is A

Explanation

A. Keep the finger in a dependent position:

  • Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.

B. Wear sterile gloves:

  • Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.

C. Select the central tip of a finger:

  • The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.

D. Test the first drop of blood that forms after the puncture:

  • The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register