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
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.
B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.
C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.
D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.
Correct Answer is D
Explanation
A. Taking pancrelipase on an empty stomach may not provide optimal effectiveness as there would be no food in the stomach to mix with the enzymes for proper digestion.
B. Taking pancrelipase 1 hour before meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
C. Taking pancrelipase 1 hour after meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
D. Taking pancrelipase with meals is the correct instruction. Pancrelipase supplements the digestive enzymes that are deficient in individuals with cystic fibrosis, helping them digest food properly. Taking it with meals ensures that the enzymes are present when food enters the stomach, optimizing digestion and nutrient absorption.
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