A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?
A client who has a burn requiring a sterile dressing change
A client who had an appendectomy 6 hr ago and has diminished bowel sounds
A client who received a chemotherapy treatment and reports nausea
A client who has hypothyroidism and is stuporous
The Correct Answer is D
A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.
B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.
C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.
D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer terbutaline subcutaneously as needed for contractions: Terbutaline is a tocolytic used to suppress preterm labor, not to manage preeclampsia or magnesium sulfate therapy. Its use is unrelated to the care of a client receiving magnesium sulfate for seizure prophylaxis.
B. Monitor the client's blood pressure every 2 hr: In severe preeclampsia, blood pressure should be monitored more frequently than every 2 hours—typically every 15–30 minutes initially—because rapid changes can occur, and close monitoring is critical to prevent complications.
C. Place suction equipment at the client's bedside: Magnesium sulfate can cause respiratory depression as a serious adverse effect. Having suction equipment readily available ensures immediate intervention if the client experiences decreased respiratory effort or airway compromise, making this an essential safety measure.
D. Notify the provider of a urinary output of less than 50 mL/hr: While low urine output can indicate magnesium accumulation or renal impairment, the typical threshold for concern is less than 30 mL/hr. Although monitoring output is important, immediate bedside readiness for respiratory support is the priority intervention when administering magnesium sulfate.
Correct Answer is B
Explanation
A. Apple juice: Thin liquids like apple juice can be difficult for clients with dysphagia to control, increasing the risk of aspiration. These should generally be thickened or avoided based on the client’s swallowing ability.
B. Oatmeal: Soft, pureed, or thick foods like oatmeal are easier to swallow and reduce the risk of aspiration. Oatmeal has a cohesive texture that allows safer swallowing for clients with dysphagia.
C. Broth: Clear liquids such as broth are thin and can easily enter the airway, increasing the risk of choking or aspiration in clients with swallowing difficulties.
D. Toast: Dry, hard foods like toast can be difficult to chew and form into a cohesive bolus, making swallowing unsafe for clients with dysphagia.
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