A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer is A
a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Assault: Assault is the threat of harm to another individual, such as threatening to administer the injection against the client's will. However, since the nurse actually administers the injection, it does not constitute assault.
b. Libel: Libel refers to a false statement that is written and published, which is not relevant in this scenario.
c. Battery: Battery involves the unauthorized or harmful physical contact with another individual, such as administering the injection without the client's consent.
d. False imprisonment: False imprisonment occurs when an individual is unlawfully restrained or confined. While the client's movement may be restricted by administering the injection, the primary issue here is the unauthorized physical contact, making battery the more appropriate choice.
Correct Answer is C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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