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. Elevate the head of the bed 45° before starting the CPM device: This is incorrect as elevating the head of the bed is not a necessary preparation for using the CPM device. The device should be used according to the specific postoperative guidelines.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect because the frame joint should generally be in an extended position to properly align the leg for movement through the device's range of motion.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct because proper alignment of the knee joint with the CPM device's frame joint is crucial to ensure that the device functions correctly and promotes effective range-of-motion exercises.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect because the degree of flexion should be adjusted according to the prescribed protocol by the healthcare provider and should not be self-adjusted by the client.
Correct Answer is B
Explanation
A. Place each sleeve under each leg with the opening at the calf: This is incorrect; the correct placement is with the opening at the thigh and the sleeve wrapped around the entire leg.
B. Ensure two fingers fit between the leg and the sleeve: This is correct as it ensures that the SCD sleeve is properly fitted and not too tight, allowing for effective compression without restricting blood flow.
C. Wrap excess tubing to the side of each leg: This is incorrect because excess tubing should not be wrapped around the leg; it should be managed to avoid kinks and ensure proper functioning of the device.
D. Ensure pressure of the device is at 25 mm Hg: This is not specific enough for all devices; the pressure setting should be according to the manufacturer's guidelines and the client's needs, often ranging between 30 and 40 mm Hg for optimal effectiveness.
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