A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?
A client who told an assistive personnel he is short of breath
A client who has a prescription for discharge
A client who received oral pain medication 30 minutes ago
A client who is scheduled for an abdominal x-ray and is awaiting transport
The Correct Answer is A
Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.
Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.
Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.
Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Cluster headaches are one of the main types of primary headaches, characterized by severe, unilateral pain around the eye.
Choice B reason: Tension-type headaches are the most common type of primary headache, often described as a constant pressure or tightness.
Choice C reason: Migraine headaches are a major type of headache characterized by intense, throbbing pain, often accompanied by nausea and sensitivity to light or sound.
Choice D reason: Stress-induced headaches are not typically classified as a primary type of functional headache; they may be a trigger for other types of headaches.
Correct Answer is C
Explanation
Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.
Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.
Choice C reason: Ineffective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.
Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.
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