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 D
Explanation
Choice A Reason:
Taking medicine with orange juice is not recommended for clients with GERD. Citrus juices, including orange juice, are highly acidic and can exacerbate GERD symptoms by increasing stomach acidity and causing reflux.
Choice B Reason:
A bedtime snack is likely to worsen heartburn rather than prevent it. Eating close to bedtime can increase the likelihood of acid reflux during the night, as lying down soon after eating can cause stomach contents to flow back into the esophagus.
Choice C Reason:
Lying down after meals is not advisable for clients with GERD. It is recommended to remain upright for at least 2-3 hours after eating to help prevent acid reflux. Lying down can increase the risk of stomach acid flowing back into the esophagus.
Choice D Reason:
Limiting activities that require bending at the waist is a good practice for managing GERD. Bending over can increase abdominal pressure and promote acid reflux. Instead, clients should try to bend at the knees or avoid such activities when possible.
Correct Answer is C
Explanation
Choice A Reason:
Taking aspirin is generally not recommended for pain management in polycystic kidney disease (PKD) patients. Aspirin can cause gastrointestinal bleeding and may affect kidney function, which is already compromised in PKD patients. Instead, acetaminophen is often recommended for pain relief.
Choice B Reason:
Reducing dietary fiber intake is not typically advised for PKD patients. In fact, a balanced diet with adequate fiber is important for overall health and can help manage symptoms such as constipation, which can be a concern for PKD patients.
Choice C Reason:
Applying dry heat to the abdomen can help alleviate pain associated with PKD. Heat therapy can relax muscles and reduce discomfort caused by the enlarged kidneys and cysts. This non-pharmacological approach is safe and can be effective in managing pain.
Choice D Reason:
Checking weight once per week is not sufficient for PKD patients. Regular monitoring of weight is important to detect fluid retention and other complications. It is generally recommended to check weight more frequently, such as daily, to promptly identify any significant changes.
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