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 A

Explanation

Choice A rationale:

When leaving a client's isolation room, the nurse should remove gloves (Choice A) first. Gloves are considered contaminated and can harbor microorganisms. Removing them first helps prevent the spread of potential pathogens to other surfaces or items while removing other personal protective equipment (PPE).

Choice B rationale:

Goggles (Choice B) protect the eyes from splashes and airborne particles. However, they should be removed after gloves. Gloves have a higher potential for contamination due to direct contact with the client and the environment.

Choice C rationale:

Removing the gown (Choice C) should follow the removal of gloves and goggles. The gown provides a barrier against potential contaminants and should be taken off to prevent self-contamination while disrobing from other PPE.

Choice D rationale:

The mask (Choice D) should be removed last. It provides respiratory protection and prevents the nurse from inhaling airborne particles. Keeping the mask on while removing other PPE items helps maintain a barrier against potential exposure to respiratory pathogens.

A. Select an injection site on the abdomen 5 cm (2 in) from the umbilicus. B. Expel the air bubble in a prefilled syringe before injecting the medication. C. Aspirate prior to injecting the medication. D. Insert the needle at a 15° angle.

Correct Answer is B

Explanation

Choice A rationale:

Selecting an injection site on the abdomen 5 cm (2 in) from the umbilicus might be an appropriate instruction for some subcutaneous injections, but the specific injection site can vary based on the medication and client's needs. This choice is not a universal instruction for all subcutaneous injections.

Choice B rationale:

Expelling the air bubble from a prefilled syringe before injecting the medication is essential to ensure accurate dosing. Air bubbles can displace medication and lead to underdosing. This step is crucial for safe and effective administration.

Choice C rationale:

Aspirating prior to injecting medication is a technique used for intramuscular injections to ensure the needle is not in a blood vessel. However, for subcutaneous injections, aspirating is not necessary or recommended, as it can cause tissue damage and discomfort.

Choice D rationale:

Inserting the needle at a 15° angle is not a standard practice for subcutaneous injections. Subcutaneous injections are typically administered at a 45° or 90° angle, depending on the needle length and client's body composition. A 15° angle would not ensure proper medication delivery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Correct Answer is A

Explanation

A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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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?