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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A.

A client who has sinus arrhythmia and is receiving cardiac monitoring.

B.

A client who has a hip fracture and a new onset of tachypnea.

C.

A client who has epidural analgesia and weakness in the lower extremities.

D.

A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%).

Answer and Explanation

The Correct Answer is B

A.    Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B.    Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C.    While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D.    An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

  • A Mantoux test: This is used to detect tuberculosis (TB) infection, especially if there's a suspicion of TB based on symptoms or exposure history.

  • A chest x-ray: This imaging test helps assess for lung conditions, including pneumonia, tuberculosis, or other pulmonary issues that might be causing the client's symptoms.

Incorrect Choices and Explanations:

  1. A nasopharyngeal swab: This is used for detecting respiratory viruses, such as influenza or COVID-19, rather than evaluating TB or general lung conditions.

  2. A pulmonary function test: This measures lung function and is used to diagnose conditions like asthma or chronic obstructive pulmonary disease (COPD), which might not be the immediate concern in an emergency setting without specific symptoms.

  3. Blood cultures: These are used to identify bacterial infections in the bloodstream rather than evaluating TB or assessing lung conditions.

Correct Answer is D

Explanation

A. It's better to document assessment findings and interventions soon after interventions to ensure accuracy and avoid forgetting details.
B. Delaying cleaning personal work area until the end of the shift could lead to clutter and inefficiency throughout the shift.
C. Gather supplies for a client's dressing change after removing the old dressing.

Supplies should be gathered beforehand to streamline the process and reduce the time the wound is exposed.
D. This approach helps maintain focus and efficiency, reducing the chance of errors and ensuring that care is fully and effectively provided to one client before moving to another.

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