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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When handling an unused portion of an oral opioid analgesic after administration, the nurse should take the following action:
D) Return the unused portion to the locked narcotics storage location.
Returning the unused portion to the locked narcotics storage location is a crucial step to ensure proper control and documentation of controlled substances like opioids. It helps prevent diversion and ensures the security and accountability of these medications.
Options A, B, and C are not appropriate:
A) Sending the unused portion to the pharmacy is not typically the responsibility of the nurse, and it may not be a practical or safe option for controlled substances.
B) Having a second nurse verify disposal of the unused portion is not a standard practice for oral medication administration.
C) Keeping the unused portion in the client's medication drawer is not an appropriate method of handling unused controlled substances, as it lacks the necessary security and accountability measures.
Correct Answer is D
Explanation
Choice A rationale:
Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.
Choice B rationale:
Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.
Choice C rationale:
Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.
Choice D rationale:
Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.
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