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 a hip fracture and a new onset of tachypnea.
A client who has diabetes mellitus and an HbA1c of 6.8%.
A client who has epidural analgesia and weakness in the lower extremities.
A client who has sinus arrhythmia and is receiving cardiac monitoring.
The Correct Answer is A
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism. The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is well- controlled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A.
Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
The correct statements that indicate an understanding of discharge teaching for a client recovering from pancreatitis are:
✅ C. "I will eat small, frequent meals." This is recommended to reduce pancreatic stimulation and aid digestion.
✅ E. "I will notify my provider if my urine is dark." Dark urine may indicate worsening jaundice or liver involvement, which requires medical attention.
❌ A. "I will eat fish for dinner at least twice per week." While fish can be part of a healthy diet, the key dietary advice for pancreatitis is to eat low-fat meals. Fatty fish may not be appropriate unless specifically recommended.
❌ B. "I will limit my morning coffee to no more than two cups." Caffeine is not directly contraindicated, but the focus is more on avoiding alcohol and fatty foods. This statement doesn’t reflect core discharge teaching.
❌ D. "I should expect my bowel movements to be pale in color." Pale stools may indicate bile duct obstruction or liver dysfunction and should be reported, not expected.
Correct Answer is C
Explanation
Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.
Choice A is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.
Choice B is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.
Choice D is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.
A client who is scheduled for surgery may have complex and unpredictable needs that require specialized knowledge and judgment by an RN.
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