A nurse is prioritizing client care after receiving 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 received oral pain medication 30 min ago
A client who is scheduled for an abdominal x-ray and is awaiting transport
A client who has a prescription for discharge
The Correct Answer is A
Choice A Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.
Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take effect.
Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.
Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because hypervolemia is a condition of excess fluid volume in the body. A client who has an extensive burn injury is more likely to have hypovolemia, which is a condition of low fluid volume, due to fluid loss from the damaged skin and capillaries.
Choice B Reason: This is incorrect because metabolic alkalosis is a condition of high blood pH and high bicarbonate level. A client who has an extensive burn injury is more likely to have metabolic acidosis, which is a condition of low blood pH and low bicarbonate level, due to increased production of lactic acid and ketones from tissue hypoxia and breakdown.
Choice C Reason: This is correct because low hemoglobin is a common laboratory finding in a client who has an extensive burn injury. Hemoglobin is the protein in red blood cells that carries oxygen. A client who has an extensive burn injury may have low hemoglobin due to hemolysis, which is the destruction of red blood cells, or hemorrhage, which is the loss of blood.
Choice D Reason: This is incorrect because hyperkalemia is a condition of high blood potassium level. A client who has an extensive burn injury may have hyperkalemia in the early phase of injury, due to cell damage and potassium release, but it is usually transient and followed by hypokalemia, which is a condition of low blood potassium level, due to fluid loss and potassium depletion.
Correct Answer is B
Explanation
Choice A Reason: Equal amount of fluid drainage in each collection chamber is not a sign of proper chest tube function. The amount of fluid drainage depends on the type and extent of the client's injury or surgery, and may vary from one chamber to another.
Choice B Reason:Fluctuation of the fluid level in the water seal chamber(tidaling) indicates that the chest tube is functioning properly. This fluctuation corresponds with the client's respirations and shows that air or fluid is being effectively removed from the pleural space.
Choice C Reason:Continuous bubbling within the water seal chamber: Continuous bubbling in the water seal chamber indicates an air leak, which is not normal unless the client has a pneumothorax and air is being evacuated. Otherwise, it suggests a problem with the system.
Choice D Reason: Absence of fluid in the drainage tubing is not a sign of proper chest tube function. It may indicate that the chest tube is obstructed, kinked, or clamped, or that the suction is not working properly. The nurse should assess and troubleshoot the chest tube system.
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