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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Child protective services deal with cases of child abuse or neglect, which isn't relevant to the parent's inability to afford medical equipment.
B. While a respiratory therapist might assist with the use of the nebulizer, they may not address the financial concerns of the parent.
C. Social workers can help connect families with resources, financial assistance programs, or charitable organizations that may assist with obtaining necessary medical equipment.
D. While a pharmacist plays a role in medication management, they may not directly address the financial concerns related to acquiring the nebulizer.

A. Administer the benzodiazepine but withhold the opioid. B. Continue the medication dosages that relieve the client's pain. C. Contact the provider about replacing the opioid with an NSAID. D. Withhold the benzodiazepine but continue the opioid.

Correct Answer is B

Explanation

A. Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B. Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C. Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D. Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.

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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

A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

Correct Answer is C

Explanation

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.Which of the following actions should the nurse take first?

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