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 epidural analgesia and weakness in the lower extremities.
A client who has diabetes mellitus and an HbA1c of 6.89%.
A client who has a hip fracture and a new onset of tachypnea.
A client who has sinus arrhythmia and is receiving cardiac monitoring.
The Correct Answer is C
Choice A rationale:
The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.
Choice B rationale:
The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.
Choice C rationale:
The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.
Choice D rationale:
The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
An advance directive is a legal document that allows a client to express their wishes regarding medical care in case they become incapacitated. The client should discuss this document with their family before signing it, so that they are aware of the client's preferences and can respect them. The other options are incorrect because the client can change their mind at any time, their partner does not need to be present, and an attorney does not need to notarize the document.
Correct Answer is B
Explanation
Choice A rationale:
Belching is a common finding following an esophagogastroduodenoscopy and is not a cause for concern unless it is excessive or accompanied by other concerning symptoms.
Choice B rationale:
(Correct Choice) Abdominal pain after an esophagogastroduodenoscopy can indicate complications such as perforation, bleeding, or infection. It is essential to report this finding to the provider promptly for further evaluation and management.
Choice C rationale:
Sore throat is a common and expected side effect after the procedure due to irritation from the endoscope. It usually resolves on its own and does not require immediate reporting unless it worsens or is associated with other concerning symptoms.
Choice D rationale:
Flatulence is not typically related to an esophagogastroduodenoscopy and is not a cause for concern in this context.
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