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
Edema, or swelling in the legs, is a common symptom of venous disease.
Hair loss distal to the client’s calves (choice B) is not a typical symptom of venous vascular disorder.
Leg pain at rest (choice C) can be a symptom of peripheral vascular disease but is not specific to venous vascular disorder.
An ulcer on the tip of a toe (choice D) can be a sign of arterial vascular disorder but is not specific to venous vascular disorder.
Correct Answer is C
Explanation
Prealbumin is a protein that is produced by the liver and is used as a marker of nutritional status.
It has a short half-life, so changes in pre albumin levels can reflect recent changes in nutritional status.
Monitoring pre albumin levels can help assess the effectiveness of total parenteral nutrition.
Lipase is an enzyme that is produced by the pancreas and is not used to monitor overall nutritional status.
B) C-reactive protein is a marker of inflammation and is not used to monitor overall nutritional status.
D) Creatinine is a waste product that is produced by muscle metabolism and is not used to monitor overall nutritional status.
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