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 A
Explanation
Rationale:
a. Droplet precautions require healthcare workers to wear a surgical mask when within 3 feet of the client to prevent the transmission of respiratory droplets containing infectious agents like influenza.
b. While high-efficiency particulate air (HEPA) filtration systems can help improve air quality, they are not specifically required for implementing droplet precautions.
c. N95 respirators are typically reserved for airborne precautions, which are not indicated for influenza.
d. Assigning the client to a room with positive airflow is not necessary for implementing droplet precautions; standard precautions such as wearing a surgical mask are sufficient.
Correct Answer is C
Explanation
a. Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b. Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c. Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d. Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.
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