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 B
Explanation
a. Advising the newly licensed nurse to complete less time-consuming tasks first may not address the underlying issue of difficulty focusing and prioritizing care effectively.
b. Recommending that the newly licensed nurse take time to plan at the beginning of his shift can help him organize tasks and prioritize care more effectively.
c. While offering to provide care for his clients while he takes a break is supportive, it does not address the underlying issue of difficulty focusing and prioritizing care.
d. Asking other staff members to take over some of his tasks may be necessary in some situations but should not be the first intervention. Helping the nurse develop strategies to improve focus and organization is more appropriate.
Correct Answer is C
Explanation
a. While telehealth may facilitate communication between providers, its primary objective is often to assess and address the needs of clients remotely.
b. Developing client treatment protocols may be a component of telehealth, but it is not its primary objective.
c. One of the main objectives of telehealth is to assess client needs remotely, allowing for the provision of healthcare services without the need for an in-person visit.
d. Providing medication reconciliation may be a component of telehealth services, but it is not its primary objective.
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