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. While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b. Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c. Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d. Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.
Correct Answer is B
Explanation
a. A system for tracking client information: While important for managing patients during a disaster, it may not be the highest priority resource in response to a bioterrorism event where protection against exposure to hazardous materials is paramount.
b. A sufficient supply of personal protective equipment: In a bioterrorism event, such as exposure to biological agents, personal protective equipment (PPE) is critical to prevent the spread of pathogens and protect healthcare workers and patients from contamination.
c. A mental health specialist on the response team: Mental health support is important for both staff and patients during and after a disaster, but it may not be the highest priority resource in the immediate response to a bioterrorism event.
d. A network for communication between staff members and families: Communication is essential during any disaster response, but ensuring an adequate supply of personal protective equipment takes precedence in the face of potential exposure to biological agents.
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