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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. A visitor experiences a minor burn after spilling coffee:
This situation does not present an ethical dilemma. It is a minor accident that can be addressed through appropriate first aid and safety measures.
b. A parent wants her 14-year-old adolescent to receive radiation treatment against his will:
This situation involves a conflict between parental authority and the autonomy of the adolescent. It raises questions about the adolescent's capacity to make medical decisions, the role of parental consent, and the rights of the adolescent to refuse treatment. Therefore, it represents an ethical dilemma.
c. A nurse witnesses another nurse administer an incorrect medication:
While this situation involves patient safety and professional responsibility, it does not inherently pose an ethical dilemma. It is a matter of patient safety and adherence to professional standards rather than conflicting moral principles.
d. A client receives an operation on the wrong side of her body:
This situation represents a serious medical error and a violation of patient safety protocols. While it may have ethical implications related to accountability, negligence, and patient harm, it primarily involves issues of medical error rather than a true ethical dilemma.
Correct Answer is D
Explanation
a. Instruct the client’s family to contact the insurance provider about the oxygen equipment:
This option involves instructing the client's family to take action by contacting the insurance provider. While it may be helpful for the family to be aware of insurance coverage, it does not directly address the immediate issue of the client needing oxygen upon discharge. Additionally, the family may not have the necessary information or authority to resolve the delivery delay.
b. Send an oxygen tank from the facility home with the client:
This option involves providing the client with an oxygen tank from the facility to ensure they have access to oxygen upon discharge. While it may temporarily address the client's immediate need, it may not be feasible or appropriate for the facility to provide oxygen equipment directly without coordinating with the equipment company and following proper protocols.
c. Contact social services about the delivery of the oxygen equipment:
This option involves contacting social services to seek assistance with resolving the delay in oxygen equipment delivery. Social services may be able to intervene and expedite the delivery process or explore alternative solutions to ensure the client's needs are met. Involving social services can be beneficial in navigating complex discharge issues.
d. Notify the provider about the delayed oxygen tank delivery:
It is important to inform the provider about the delay in oxygen equipment delivery so they can be aware of the situation and make any necessary adjustments to the discharge plan or arrange for alternative solutions. The provider may also assist in expediting the delivery or provide additional instructions for managing the situation.
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