A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

A client who has early dementia and awoke confused to their location this morning

A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning

A client who has pneumonia and has developed wheezing

A client who is postoperative and has a urine output of 50 mL for the past 3 h

Answer and Explanation

The Correct Answer is C

A) A client who has early dementia and awoke confused to their location this morning:
Confusion in a client with early dementia could indicate a range of possible causes, such as infections, medication side effects, or changes in routine. However, while this warrants investigation, confusion alone does not represent an immediate life-threatening situation according to the ABCDE priority framework. The focus is on managing airway, breathing, circulation, and disability issues first.

B) A client who is scheduled for discharge and has a 38.4°C (101.1°F) temperature this morning:
A fever may indicate infection, which would require further assessment and potentially treatment. While this is a concern, it does not immediately threaten the client's airway, breathing, or circulation. Since the client is not in an acute crisis and is scheduled for discharge, this would be a lower priority compared to clients with more urgent issues like breathing problems or insufficient urine output.

C) A client who has pneumonia and has developed wheezing:
Wheezing indicates potential airway constriction, which could impair the client's breathing. Given that breathing difficulties are a primary concern in the ABCDE priority framework (Airway, Breathing, Circulation, Disability, and Exposure), this client requires immediate attention. Pneumonia combined with wheezing can signify a worsening respiratory condition, which poses an acute risk to the client's oxygenation and overall stability.

D) A client who is postoperative and has a urine output of 50 mL for the past 3 hours:
Oliguria (low urine output) postoperatively is concerning, as it may indicate kidney dysfunction, hypovolemia, or other complications. While it is an important issue that requires attention, it is not immediately life-threatening unless the client shows signs of worsening shock or kidney failure. However, given that this issue does not immediately affect the client’s airway or breathing, it is a lower priority than the client with pneumonia and wheezing.

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Correct Answer is A

Explanation

A) Cataracts:
A cloudy, opaque area over the lens of the eye is a classic sign of cataracts. Cataracts occur when the lens of the eye becomes cloudy or opaque, leading to blurry vision and, in some cases, eventual blindness if left untreated. Cataracts typically develop slowly and can be caused by aging, injury, or other conditions like diabetes. Symptoms include difficulty seeing at night, glare, and a decrease in color intensity.

B) Diabetic retinopathy:
Diabetic retinopathy is a complication of diabetes that affects the blood vessels of the retina. It leads to vision problems such as blurred vision, floaters, and even blindness. However, it is characterized by damage to the retina, not cloudiness or opacity over the lens.

C) Macular degeneration:
Macular degeneration affects the macula, the part of the retina responsible for central vision. It leads to a loss of central vision, causing difficulty with tasks like reading or recognizing faces. There is often blurriness or distortion in the center of the visual field.

D) Glaucoma:
Glaucoma is a group of eye conditions that lead to damage to the optic nerve often due to high intraocular pressure. It can result in peripheral vision loss and, if untreated, can lead to blindness. However, glaucoma does not cause a cloudy, opaque lens but rather affects the optic nerve and peripheral vision.

A. Crushing the medication would release all the medication at once, rather than over time." B. Crushing the medication might cause you to have a stomachache or indigestion. C. "Crushing the medication is a good idea, and I can mix in some ice cream for you." D. "Crushing is unsafe, as it destroys the ingredients in the medication."

Correct Answer is B

Explanation

A) Crushing the medication would release all the medication at once, rather than over time:. Enteric-coated aspirin is designed to bypass the stomach and release the medication in the small intestine to avoid irritation of the stomach lining. Crushing the tablet could potentially release the entire dose all at once, which could lead to gastrointestinal irritation, but this isn't the primary concern. The key issue is that crushing destroys the enteric coating, which is crucial for protecting the stomach.

B) Crushing the medication might cause you to have a stomachache or indigestion:
Enteric-coated medications are specifically designed to protect the stomach lining by delaying the release of the drug until it reaches the small intestine. Crushing the medication would destroy the enteric coating, which can lead to stomach irritation, upset, or even ulcer formation due to the direct exposure of the stomach lining to the medication. Therefore, crushing could cause significant discomfort or damage to the digestive system.

C) "Crushing the medication is a good idea, and I can mix in some ice cream for you.":
Crushing enteric-coated medications, such as aspirin, can lead to adverse effects like stomach irritation, ulceration, and poor absorption. The nurse should not recommend this method of administration without first consulting with the prescribing provider or pharmacist to explore alternatives.

D) "Crushing is unsafe, as it destroys the ingredients in the medication.":
Crushing does not destroy the active ingredients in the medication, but it does destroy the enteric coating, which is the key concern. The enteric coating's function is to prevent the aspirin from irritating the stomach. While it's important to recognize that crushing is unsafe, the reason is more about the loss of this protective coating rather than the destruction of the medication's active ingredients themselves.

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A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

Correct Answer is A

Explanation

A nurse is caring for client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

Correct Answer is B

Explanation

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