A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?
A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL
A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
The Correct Answer is B
A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.
B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.
C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.
D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cooperating:Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding:Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising:Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.
Correct Answer is A
Explanation
A. Fluctuation of the fluid level within the water seal chamber
Fluctuation of the fluid level within the water seal chamber indicates that the chest tube is functioning properly. This fluctuation is a normal finding and reflects the movement of air in and out of the pleural space during the respiratory cycle. As the patient inhales, the fluid level drops, and as they exhale, it rises.
B. Equal amounts of fluid drainage in each collection chamber:
Equal amounts of drainage may suggest a problem with the drainage system or that the chest tube is not effectively draining air or fluid from the pleural space.
C. Continuous bubbling within the water seal chamber:
Continuous bubbling in the water seal chamber may indicate an air leak, which is not a normal finding. It should be investigated further.
D. Absence of fluid in the drainage tubing:
The absence of fluid in the drainage tubing may suggest that the chest tube is not effectively draining fluid from the pleural space or that there is a blockage in the system. It requires assessment and intervention.
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