A nurse is prioritizing care for four clients following change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has Alzheimer's disease and requires assistance to the bathroom
A client who has diverticulitis and a temperature of 38.3° C (100.9° F)
A client who has a prescription for a sputum specimen to be obtained before breakfast
A client who sustained a head injury 2 days ago and has a decreased level of consciousness
The Correct Answer is D
A. A client who has Alzheimer's disease and requires assistance to the bathroom: This is important but less urgent compared to the risk of worsening condition in a client with a decreased level of consciousness.
B. A client who has diverticulitis and a temperature of 38.3° C (100.9° F): This is a concern, but it is not as immediately critical as a decreased level of consciousness, which may indicate a more severe underlying issue.
C. A client who has a prescription for a sputum specimen to be obtained before breakfast: While important for diagnostic purposes, this is less urgent compared to a decreased level of consciousness.
D. A client who sustained a head injury 2 days ago and has a decreased level of consciousness: This is correct because a decreased level of consciousness in a client with a recent head injury could indicate a serious complication, such as increased intracranial pressure or worsening of their condition, requiring immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Intermittent abdominal pain: While abdominal pain may occur, it is not specifically related to total parenteral nutrition (TPN) and burn care.
B. Decreased calcium levels: Decreased calcium levels are not the primary concern with TPN. Calcium levels should be monitored, but other issues are more directly related to TPN.
C. Increased serum glucose levels: This is correct as TPN often contains high levels of glucose, which can lead to hyperglycemia. Monitoring serum glucose levels is crucial in managing TPN to avoid complications.
D. Absent bowel sounds: Bowel sounds are not directly affected by TPN. However, monitoring for gastrointestinal function is important in the overall assessment of the client.
Correct Answer is C
Explanation
A. "Knee-high stockings can be rolled down slightly to provide comfort": Rolling down antiembolic stockings can cause bunching and reduce their effectiveness in preventing deep vein thrombosis. They should fit smoothly without rolling.
B. "I should flex my toes when applying the stockings": To apply the stockings, the toes should be pointed or relaxed, not flexed, to ensure proper application and avoid discomfort.
C. "The thigh-high stockings should reach just above the gluteal folds": This is correct as thigh-high stockings should extend to just above the gluteal folds to ensure proper fit and effectiveness in preventing blood clots.
D. "I should reapply the stockings before I get out of bed": Antiembolic stockings are typically applied in the morning after getting out of bed and should remain on throughout the day. Reapplying before getting out of bed is not necessary.
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