A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10.
A client who received parenteral cephalosporin and reports urticaria and edema.
A client who is being admitted with bilateral stage 3 pressure injuries on both heels.
A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F).
The Correct Answer is B
Choice A Reason
A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.
Choice B Reason
A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.
Choice C Reason
A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.
Choice D Reason
A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason
Expressive aphasia is a common symptom of a left-hemisphere stroke. This condition, also known as Broca’s aphasia, affects the ability to produce language, making it difficult for the patient to speak fluently. The patient may understand speech but struggle to form coherent sentences, often speaking in short, choppy phrases.
Choice B Reason
Poor impulse control is more commonly associated with right-hemisphere strokes. The right hemisphere of the brain is responsible for controlling impulsive behavior and emotional regulation. Therefore, this symptom is less likely to be observed in a patient with a left-hemisphere stroke.
Choice C Reason
Left hemiparesis refers to weakness on the left side of the body. Since the left hemisphere of the brain controls the right side of the body, a left-hemisphere stroke typically results in right-sided weakness or paralysis. Therefore, left hemiparesis is not a typical finding in this scenario.
Choice D Reason
Disorientation to place can occur after a stroke, but it is not specifically associated with left-hemisphere strokes. Disorientation is a general symptom that can result from various types of brain injuries and is not exclusive to strokes affecting the left hemisphere.
Correct Answer is B
Explanation
Choice A Reason:
Increasing hydration is important in the postoperative period to maintain fluid balance and support recovery. However, it is not the immediate priority following pheochromocytoma removal. The primary concern is to monitor and manage hemodynamic stability, particularly blood pressure.
Choice B Reason:
Monitoring blood pressure is the priority action following pheochromocytoma removal. This surgery can lead to significant fluctuations in blood pressure due to the sudden removal of catecholamine-secreting tumors. Close monitoring is essential to detect and manage potential hypotension or hypertension, which can be life-threatening if not promptly addressed.
Choice C Reason:
Measuring urine output is important for assessing kidney function and fluid balance, but it is not the immediate priority. Blood pressure monitoring takes precedence because of the potential for severe hemodynamic instability following the removal of the tumor.
Choice D Reason:
Providing a calm environment is beneficial for the patient’s overall recovery and can help reduce stress and anxiety. However, it is not the most critical action immediately following surgery. Ensuring hemodynamic stability through blood pressure monitoring is the top priority.
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