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?
client who has a hip fracture and a new onset of tachypnea
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
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
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 wellcontrolled 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.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
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 wellcontrolled 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 B
Explanation
Choice A Reason:
Urine specific gravity: The specific gravity of 1.035 indicates concentrated urine and might be indicative of dehydration. However, the nurse should address this finding by encouraging increased fluid intake before reporting it to the provider.
Choice B Reason:
Prealbumin: The prealbumin level is 25 mg/dL. Prealbumin is a marker of nutritional status and can indicate the adequacy of protein intake and overall nutritional status. A level of 25 mg/dL is relatively low, which may suggest malnutrition or insufficient protein intake. This finding should be reported to the provider so that appropriate interventions can be initiated to address the client's nutritional needs.
Choice C Reason:
Temperature: The temperature is not mentioned in the provided information. If the temperature is within the normal range, there is no need to report it to the provider.
Choice D Reason:
Blood pressure: The blood pressure is not mentioned in the provided information. If the blood pressure is within the normal range, there is no need to report it to the provider.
It's important for the nurse to critically assess the client's medical record and prioritize the findings that require immediate attention or intervention. In this case, the low prealbumin level indicates a potential nutritional issue that needs to be addressed promptly. The nurse should communicate this finding to the healthcare provider to ensure appropriate management and care for the client.
Correct Answer is B
Explanation
Choice A reason:
Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.
Choice B reason:
Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.
After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.
Choice C reason:
Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.
Choice D reason:
Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.
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