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 B
Explanation
A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.
B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.
C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.
D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.
Correct Answer is A
Explanation
A. Contacting the case manager is crucial to explore various discharge options and ensure the client's needs are met appropriately.
B. Recommending long-term care should be considered after exploring other options and assessing the client's specific needs.
C. Requesting assistance from another family member is a potential option but should be explored in conjunction with other solutions.
D. Delaying discharge might not address the partner's inability to provide care and doesn't explore alternative solutions.
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