A nurse is caring for four clients. Which of the following should the nurse assess first?

A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness

A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

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Correct Answer is D

Explanation

a. A client is refusing care from assistive personnel of the opposite gender:

This situation involves the client's right to refuse care based on personal preferences or cultural beliefs. While it requires attention and respect for the client's wishes, it may not pose an immediate risk to patient care or staff safety.

b. No transport assistance is available to take a client to physical therapy:

This can be resolved by contacting the transportation department or finding an alternative solution, but it is not a critical issue that requires immediate attention.

c. Two nurses had a heated disagreement about a scheduling issue:

While workplace conflicts should be addressed to promote a positive work environment, a heated disagreement about a scheduling issue may not pose an immediate threat to patient care. However, if the disagreement escalates or affects staff morale, it could impact unit functioning and require intervention.

d. Three staff members have called to say they will be absent:

This situation has the most immediate impact on the overall functioning of the unit. Staffing shortages can affect patient care and safety, so it is crucial to address this issue promptly to ensure adequate coverage and maintain the quality of care.

A. Involve the client’s partner to assist with the teaching session B. Incorporate gestures and hand signals when presenting information C. Validate understanding by interpreting the client’s body language D. Provide an interpreter when obtaining consent from the client

Correct Answer is D

Explanation

a. Involve the client’s partner to assist with the teaching session: While involving the client's partner can be helpful, it may not ensure effective communication if the partner also does not speak the same language as the client.

b. Incorporate gestures and hand signals when presenting information: This is an effective strategy to enhance communication with a client who speaks a different language. Non-verbal cues such as gestures and hand signals can help convey meaning and facilitate understanding.

c. Validate understanding by interpreting the client’s body language: Interpreting the client's body language can be helpful in assessing their level of understanding and engagement. However, it may not be sufficient for effective communication, especially if the client has questions or needs clarification.

d. Provide an interpreter when obtaining consent from the client: This is the most appropriate intervention. Using a professional interpreter ensures accurate communication between the nurse and the client, facilitating understanding and ensuring that the client's rights are upheld during the consent process.

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A nurse is caring for four clients. Which of the following should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is receiving report and is faced with the following situations that require interventions. Which of the following should the nurse manager address first?

Correct Answer is D

Explanation

A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to include?

Correct Answer is D

Explanation

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A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?

A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. The client tells the nurse she has decided to go home. Which of the following actions should the nurse take?

A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescription in the client’s medical record?

A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?

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