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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Elevate the client’s head of bed:
Elevating the head of the bed is a good practice for patients on mechanical ventilation as it helps prevent complications such as aspiration. However, in the scenario where the client has pulled out the endotracheal tube, the immediate concern is assessing the airway and ensuring adequate oxygenation and ventilation. Elevating the head of the bed can be done later as needed.

B. Assess the client’s airway:
This is the correct and priority action. The nurse should assess the client's airway first to determine the extent of the situation. This involves checking for signs of airway obstruction, respiratory distress, or inadequate oxygenation. The assessment guides subsequent interventions.

C. Prepare the client for intubation:
While preparing for intubation may be necessary if the endotracheal tube is completely displaced, assessing the airway comes first. The nurse needs to gather information about the client's current condition before deciding on the appropriate course of action.

D. Suction the client’s mouth:
Suctioning may be necessary, especially if there are secretions or other obstructions in the mouth or airway. However, it should come after the initial assessment of the airway. If the client's airway is clear, suctioning may not be the immediate priority.

A. Reduces inflammation B. Dries mucous membranes C. Stimulates secretions D. Suppresses the urge to cough

Correct Answer is C

Explanation

A. Reduces inflammation:
This action is more characteristic of anti-inflammatory medications, such as corticosteroids. Expectorants, however, do not primarily reduce inflammation.

B. Dries mucous membranes:
This action is more characteristic of antihistamines or decongestants, which may help reduce nasal congestion by drying mucous membranes. Expectorants have the opposite effect; they promote the thinning of mucus.

C. Stimulates secretions
An expectorant is a type of medication that works by promoting the clearance of mucus from the respiratory tract. It does so by thinning and loosening mucus, making it easier for the patient to cough up and expel. Expectorants help in facilitating the removal of excessive mucus and can be useful in conditions where there is a productive cough associated with excessive mucus production.

D. Suppresses the urge to cough:
This action is associated with antitussive medications, which are cough suppressants. Expectorants, on the other hand, stimulate the removal of mucus and do not suppress the urge to cough

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has following actions?

Correct Answer is C

Explanation

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

A student is caring for a patient with positive end-expiratory pressure (PEEP) at 5 cm H20. The student asks “What is the purpose of PEEP?” which of the following is an appropriate response by the nurse?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance?

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client’s care?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?