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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

A. Proceed with treatment without obtaining written consent B. Notify risk management before initiating treatment C. Have the client sign a consent for treatment D. Contact the client's next of kin to obtain consent for treatment

Correct Answer is A

Explanation

a. In emergency situations where immediate treatment is necessary to stabilize the client and prevent further deterioration, obtaining written consent may not be feasible or necessary. The principle of implied consent applies in emergency situations where the client is unable to provide consent due to their condition.

b. Notifying risk management before initiating treatment is not necessary in this emergency situation, as the priority is to provide timely and appropriate care to the client.
c. Having the client sign a consent for treatment may not be possible if the client is disoriented or incapacitated due to their condition.

d. Contacting the client's next of kin to obtain consent may delay necessary treatment, which could be detrimental to the client's health in an emergency situation.

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A nurse is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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