A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?
A client who has type 2 diabetes mellitus needs assistance counting the carbohydrates in her meal.
A client who has a new tracheostomy is experiencing coughing episodes.
A client who has a BMI of 17 refuses his dinner tray.
A client awaiting discharge needs to demonstrate colostomy care before leaving.
The Correct Answer is B
A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While connecting the client with others may provide support, it does not directly address the client’s frustrations or concerns about their therapy.
B. Asking the provider to speak with the client directly can facilitate communication about their concerns and may help address their frustrations regarding the plan of care.
C. Threatening the client with consequences for leaving is not appropriate and may increase their frustration and disengagement from care.
D. It is important to respect the client’s autonomy and right to leave, so informing them they cannot leave is not appropriate or legal without proper discharge procedures being followed.
Correct Answer is A
Explanation
A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.
B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.
C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.
D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.
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