A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who has dehydration with a urine output of 40 mL/hr.

A client who has cancer and reports pain as 4 on a scale of 0 to 10.

A client who has asthma and a respiratory rate of 40/min.

A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.

Choice B rationale:

Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.

Choice C rationale:

(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.

Choice D rationale:

A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.

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Correct Answer is C

Explanation

The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”

Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.

Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.

Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.

Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.

A. Slowly instill 400 to 500 mL of the prescribed solution. B. Clamp the drainage tubing distal to the injection port. C. Use a syringe with a 19-gauge needle. D. Withdraw the irrigation solution into the syringe.

Correct Answer is A

Explanation

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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