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 A

Explanation

a. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

c. Tell the charge nurse that the visitor viewed a client’s protected health information:

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

A. Store opened bottles of normal saline in a refrigerator for up to 48 hr B. Wait to dispose of sharps containers until they are completely full C. Use clean gloves rather than sterile gloves for colostomy care D. Return unused supplies from the bedside to the unit’s supply stock

Correct Answer is ["C"]

Explanation

a. Store opened bottles of normal saline in a refrigerator for up to 48 hours:

Incorrect. Once opened, bottles of normal saline should generally be used within a short time frame (typically 24 hours) and should not be stored for extended periods to prevent contamination. This practice could lead to infection risks and is not recommended as a cost-containment measure.

b. Wait to dispose of sharps containers until they are completely full:

Incorrect. Overfilling sharps containers increases the risk of needle-stick injuries and potential exposure to bloodborne pathogens. Sharps containers should be disposed of when they are about three-quarters full to maintain safety.

c. Use clean gloves rather than sterile gloves for colostomy care:

Correct. For colostomy care, clean gloves are generally sufficient as it is a clean procedure, not a sterile one. Using clean gloves instead of sterile gloves reduces costs without compromising patient safety.

d. Return unused supplies from the bedside to the unit’s supply stock:

Incorrect. Returning unused supplies to the general supply stock can pose a risk of cross-contamination and infection. Once supplies have been brought to a patient's bedside, they are considered contaminated and should not be returned to the supply area.

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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

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Correct Answer is ["C"]

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