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. 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.
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
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