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. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.
B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.
C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.
D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.
Correct Answer is C
Explanation
A. Metallic taste in the mouth:
This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing:
Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema:
Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
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