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A nurse on a medical-surgical unit has received change-of-shift report for six clients. They have received additional information from assistive personnel (AP).

Complete the following sentence by using the lists of options.

The nurse should first collect data on

followed by.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Rationale for correct choices:

• Client 1: The client with pneumonia has an oxygen saturation of 88% on 2 L/min oxygen, indicating hypoxemia. Immediate assessment and intervention are required to prevent respiratory failure, making this the highest-priority client based on airway and breathing status.

• Client 4: The client with hypertension has a blood pressure of 170/98 mm Hg, which is significantly elevated and may put the client at risk for end-organ damage. After addressing the airway/oxygenation concern, this client requires timely assessment and interventions to reduce the risk of complications such as stroke or myocardial infarction.

Rationale for incorrect choices:

• Client 2: The client with a blanchable sacral area is at risk for pressure injury, but stage 1 pressure areas are not immediately life-threatening. This requires monitoring and preventive care but is lower priority than airway or hypertensive crisis.

• Client 3: The preoperative client has a fever of 39° C, which warrants evaluation, but immediate life-threatening compromise is not present. Fever can be managed after more urgent priorities like hypoxemia are addressed.

• Client 5: A weight gain of 1.1 kg (2.4 lb) in 24 hours indicates fluid retention, but it is not immediately life-threatening. Monitoring and assessment can follow higher-priority concerns.

• Client 6: Multiple loose stools from enteral feedings can cause dehydration or electrolyte imbalance, but the immediate risk is lower compared with hypoxemia or severe hypertension. This can be addressed after higher-priority clients.


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Related Questions

Correct Answer is B

Explanation

A. Assist in revising the plan of care: Revising the care plan is important for preventing future falls, but it is not the immediate priority. The nurse must first assess the client’s physical condition after the fall.

B. Check the client for injuries: Assessing for injuries addresses the client’s immediate safety and physical well-being, including potential fractures, head trauma, or internal injuries. This is the first action to determine the need for urgent medical intervention.

C. Complete an incident report: Documentation is essential for legal and quality improvement purposes, but it should be completed after the client’s safety and medical needs are addressed.

D. Notify the client's provider: The provider should be informed if injuries or complications are present, but notification occurs after assessing the client’s condition to provide accurate information and guidance.

Correct Answer is A

Explanation

A. Hypokalemia: Chronic diarrhea causes excessive loss of potassium through the gastrointestinal tract, leading to low serum potassium levels. Signs can include muscle weakness, fatigue, and cardiac arrhythmias. Monitoring electrolytes and providing potassium replacement as needed are critical in these clients.

B. Respiratory acidosis: Diarrhea primarily causes metabolic disturbances, not respiratory. Respiratory acidosis results from hypoventilation or impaired gas exchange, which is unrelated to gastrointestinal fluid loss.

C. Hypertension: Chronic diarrhea typically leads to fluid and electrolyte depletion, which can lower blood pressure rather than elevate it. Hypertension is not an expected finding in this context.

D. Hypermagnesemia: Diarrhea usually results in magnesium loss, not accumulation. Hypermagnesemia is more commonly associated with renal insufficiency or excessive magnesium intake, not chronic GI losses.

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