A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who is 3 days postoperative following abdominal surgery is ready for discharge
A client who has Alzheimer's disease and bacterial pneumonia with newly onset restlessness
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
The Correct Answer is B
A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Recommending that the newly licensed nurse take time to plan at the beginning of the shift can help improve focus and organization, allowing for better task completion.
B. Offering to take over care while he takes a break might provide immediate relief but doesn't address the underlying issue of focus and task completion.
C. Advising to complete less time-consuming tasks first might not necessarily address the root cause of the difficulty in focusing.
D. Asking other staff members to take over tasks doesn't encourage skill development or help the newly licensed nurse develop coping strategies for focus and task completion.
Correct Answer is A
Explanation
A. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or penicillin, making preparation to administer antibiotics the appropriate action.
B. While respiratory precautions might be necessary in cases of inhalational anthrax, cutaneous anthrax does not typically require the use of an N95 respirator mask.
C. Antiviral medications are not the standard treatment for cutaneous anthrax; antibiotics are the primary treatment.
D. Placing a surgical mask on the client during transfer might not be necessary for cutaneous anthrax exposure, as the mode of transmission is not through respiratory droplets.
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