A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

A client who has gastroenteritis and is lethargic and confused

A client who has cystic fibrosis, has a thick, productive cough, and reports thirst

A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic

A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL

Answer and Explanation

The Correct Answer is A

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

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Correct Answer is B

Explanation

A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.

A. Initiate an IV access for the client. B. Administer pain medication to the client. C. Send the client to radiology for a CT scan. D. Insert an NG tube for the client.

Correct Answer is A

Explanation

A. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

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A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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