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 multiple sclerosis and reports ataxia and vertigo

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%

A client who has left-sided paralysis and slurred speech from a prior stroke

A client who has thrombocytopenia and reports a nosebleed

Answer and Explanation

The Correct Answer is D

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

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Correct Answer is A

Explanation

The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.

The other actions are important but not as urgent as obtaining consent.

A. Increase the client's fluid intake. B. Check the client's urine output. C. Reposition the client in bed. D. Administer PRN pain medication.

Correct Answer is B

Explanation

Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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