A nurse on a medical unit is planning care for a group of clients.
Which of the following clients should the nurse attend to first?
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%.
A client who has thrombocytopenia and reports a nosebleed.
A client who has left-sided paralysis and slurred speech from a prior stroke.
A client who has multiple sclerosis and reports ataxia and vertigo.
The Correct Answer is B
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first.
Thrombocytopenia is a condition characterized by low platelet count, which increases the risk of bleeding.
A nosebleed can be a sign of significant bleeding, and it is important for the nurse to assess the severity and take appropriate action to stop the bleeding and prevent further complications.
Although the other clients also require nursing care, their conditions are not as urgent as the client with thrombocytopenia and a nosebleed.
The client with chronic obstructive pulmonary disease and an oxygen saturation of 89% may require oxygen therapy or other interventions to improve respiratory function, but the situation is not immediately life-threatening.
The client with left-sided paralysis and slurred speech from a prior stroke may require ongoing care and rehabilitation, but there is no indication of an acute change in their condition.
The client with multiple sclerosis and ataxia and vertigo may require assistance with mobility and balance, but their symptoms do not pose an immediate threat to their health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acupuncture is commonly used to treat a wide range of illnesses and ailments including pain management, control of nausea and vomiting, fatigue, hot flashes, xerostomia, neuropathy, anxiety, depression, and sleep disturbance in cancer patients.
However, I could not find any information that suggests mouth sores (B), headaches, or urticaria (D) are contraindications for acupuncture.
Lymphedema is a contraindication for acupuncture because it can increase the risk of infection in the affected area.
It is important for the nurse to identify this as a contraindication to receiving acupuncture therapy.
Correct Answer is D
Explanation
The correct answer isChoice D.
Choice A rationale:Checking potassium levels is important in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale:Bicarbonate infusion is not the priority intervention in the management of DKA.It is used only in severe cases of metabolic acidosis
Choice C rationale:Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale:Administering 0.9% sodium chloride is the priority intervention in the management of DKA.It is used to restore intravascular volume and correct electrolyte imbalances
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today