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 ["10"]
Explanation
• Desired dose: 25 mg
• Available concentration: 12.5 mg/5 mL
• To find the volume to administer, we can use the formula:
• Volume to administer (mL) = Desired dose (mg) / Concentration (mg/mL)
• First, we need to find the concentration in mg/mL:
• Concentration = 12.5 mg / 5 mL = 2.5 mg/mL
• Now, we can calculate the volume:
• Volume to administer = 25 mg / 2.5 mg/mL = 10 mL
Correct Answer is D
Explanation
A. A padded tongue blade: A padded tongue blade is not recommended as it can cause injury to both the client and the nurse. It is a common misconception that it should be used during a seizure, but it does not prevent injury.
B. Anticonvulsant medication: While important for managing seizures, anticonvulsant medication is not an equipment item to be placed at the bedside. It is typically administered as per the prescription and monitored by healthcare providers.
C. A nasogastric tube: A nasogastric tube is not relevant for seizure precautions and is used for different medical purposes, such as feeding or gastric decompression.
D. A suction machine: This is correct as a suction machine is essential to clear the airway in case of aspiration during or after a seizure. It helps in maintaining airway patency and preventing complications.
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