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 client who has sinus arrhythmia and is receiving cardiac monitoring.

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

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

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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Correct Answer is B

Explanation

A. While revising the current policy for catheter care may be necessary, it is not the first step in addressing the increase in infections. Understanding the factors contributing to the infections is crucial before policy revision.
B. Identifying possible precipitating factors related to the infections is the first step in addressing the issue. This involves investigating the circumstances surrounding the infections to determine potential causes and contributing factors.
C. While staff training is important, scheduling training before understanding the root cause of the infections may not effectively address the problem.
D. Meeting with providers to discuss measures to decrease infections may be necessary, but it should occur after identifying the precipitating factors to ensure targeted and effective interventions.

A. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums

Correct Answer is A

Explanation

A: This could be a sign of preeclampsia, a serious condition that requires immediate medical attention due to its potential to cause high blood pressure, proteinuria, and seizures, affecting both the mother and fetus.
B: Urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus; it's not typically a concern unless accompanied by pain or other symptoms.

C: Faintness upon rising can be related to changes in blood pressure or blood volume during pregnancy, but it's not specific to the second trimester and is often transient.This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
D: Bleeding gums are also a common symptom due to hormonal changes increasing blood flow to the gums, and while it should be monitored, it is not typically a cause for alarm unless accompanied by other symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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