A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube

A preschooler awaiting discharge instructions prior to leaving the hospital

A toddler who has a respiratory rate of 54/min

A school-age child who reports nausea following chemotherapy

Answer and Explanation

The Correct Answer is C

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Limit crossing your legs at your knees to 30 minutes at a time: Crossing the legs at the knees can restrict blood flow and increase venous pressure, which is detrimental to clients with venous insufficiency. It's generally advised to avoid crossing legs altogether rather than limiting it to 30 minutes.

B) Elevate the head of the bed when sleeping at night: Elevating the head of the bed does not significantly aid in improving venous return from the legs. Elevating the legs instead helps reduce venous pressure and promotes better circulation, which is more beneficial for venous insufficiency.

C) Wash your graduated compression stockings in the washing machine: Washing compression stockings in a washing machine can damage their elasticity and effectiveness. It's better to hand wash them and let them air dry to maintain their compression properties.

D) Put on your graduated compression stockings before getting out of bed: Putting on compression stockings before getting out of bed helps to prevent blood from pooling in the legs. This maximizes their effectiveness in reducing edema and promoting venous return throughout the day.

A. Hispanic ethnicity B. Cholesterol 190 mg/dL C. BMI of 28 D. History of atrial fibrillation.

Correct Answer is C

Explanation

A) Hispanic ethnicity: While ethnicity can influence the prevalence and risk of hypertension, Hispanic ethnicity alone is not a direct risk factor for hypertension. Other factors such as lifestyle, diet, and genetic predispositions play more significant roles in the development of hypertension.

B) Cholesterol 190 mg/dL: Although elevated cholesterol levels can contribute to cardiovascular disease, a cholesterol level of 190 mg/dL is considered borderline high but not a primary risk factor for hypertension. The risk for hypertension is more directly related to factors like blood pressure levels and weight.

C) BMI of 28: A Body Mass Index (BMI) of 28 falls into the overweight category, which is a known risk factor for developing hypertension. Excess body weight can increase blood pressure by increasing the workload on the heart and contributing to insulin resistance, which can further elevate blood pressure.

D) History of atrial fibrillation: While atrial fibrillation is a significant cardiac condition and can be associated with other cardiovascular risks, it is not a direct risk factor for the development of hypertension. The primary risk factors for hypertension include factors like obesity, diet, and physical inactivity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has venous insufficiency due to deep-vein thrombosis. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse in a provider's office is reviewing the medical record of a client. The nurse should identify which of the following findings as a risk factor for the development of hypertension?

Correct Answer is C

Explanation

A nurse is reviewing the medical record for a client who has hypothyroidism and is experiencing myxedema coma. Which of the following findings should the nurse expect?

A nurse in an emergency department is caring for a client who has a compound fracture of the right tibia. Which of the following actions should the nurse take?

A nurse is planning care using systematic desensitization for a client who has severe claustrophobia. Which of the following interventions should the nurse include in the plan of care?

A nurse is providing teaching to a client who has type 1 diabetes mellitus and her partner about how to manage severe hypoglycemia at home. Which of the following actions should the nurse instruct the partner to perform first?

A nurse is reviewing the laboratory results of a client who was an unrestrained passenger in a motor-vehicle crash. The ABG results are as follows: pH 7.32, HCO3 24 mEq/L, PaCO2 48 mm Hg. The nurse should identify the client is experiencing which of the following acid-base imbalances?

A nurse is preparing to perform a capillary blood glucose test for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is providing teaching about food selection to a client who has iron-deficiency anemia. Which of the following client statements should the nurse identify as an understanding of the teaching?

A nurse is assessing a client who has vision impairment related to acute angle-closure glaucoma. Which of the following manifestations should the nurse expect?