A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?
An older adult client who is anxious and attempting to pull out an IV line
A middle adult client who is reporting nausea after receiving pain medication
An older adult client who has kidney failure and returned from dialysis 4 hr ago
A middle adult client who has a terminal illness and is requesting a visit from the chaplain
The Correct Answer is A
- A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.
- B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.
- C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.
- D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.
- B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.
- C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.
- D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.
Correct Answer is B
Explanation
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
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