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 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.

A. "You should contact the provider about your wishes for your family member." B. "You should speak with the facility's ethics committee about your concerns." C. "As the health care surrogate, the client's partner can make this decision." D. "We'll need to have the nursing supervisor review the client's advance directives."

Correct Answer is C

Explanation

A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.

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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 preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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