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.
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Related Questions
Correct Answer is C
Explanation
This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.
The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
Choice B is wrong because a client who received pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.
Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.
Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.
Correct Answer is D
Explanation
A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus. The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack.
Watching television can increase the stimuli in the client’s environment, which can worsen anxiety.
The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client’s level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack.
Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.
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