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 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.

A. Contact the nurse manager. B. Call risk management to interview the client. C. Reassure the client that the staff is well trained. D. Document in the client's chart that an incident report has been filed.

Correct Answer is A

Explanation

A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.

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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 B

Explanation

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Correct Answer is A

Explanation

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