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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Absence seizures typically last for a few seconds, not 30 to 60 seconds. This choice is incorrect because it provides inaccurate information about the duration of absence seizures.

Choice B rationale:

Absence seizures are brief episodes of staring that can be mistaken for daydreaming. It is crucial for the parent to recognize this symptom to ensure the child's safety and seek appropriate medical attention if needed.

Choice C rationale:

Absence seizures usually occur without warning or an aura. There is no specific warning sign before the onset of absence seizures, making this choice incorrect.

Choice D rationale:

Absence seizures have a sudden onset and offset without any warning signs, so they do not have a gradual onset. This information is incorrect regarding absence seizures.

A. Tie a tourniquet around the leg distal to the wound. B. Irrigate the wound with sterile water. C. Apply direct pressure to the wound with thick dressing material. D. Apply a transparent dressing to the wound.

Correct Answer is C

Explanation

View Question and Answer

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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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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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?