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 multiple sclerosis and reports ataxia and vertigo

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 A

Choice A Reason:

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.

Choice B Reason:

A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.

Choice C Reason:

A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.

Choice D Reason:

A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.

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Correct Answer is C

Explanation

Choice A Reason:

Changing the catheter dressing daily - While it's important to maintain the dressing and keep it clean and dry, changing the dressing daily might not be necessary. The dressing should be changed according to facility policy and based on assessment findings.

Choice B Reason:

Cleaning the insertion site using 20 mL of hydrogen peroxide - Hydrogen peroxide is not recommended for cleaning PICC line insertion sites, as it can cause tissue irritation. The insertion site should be cleaned with an appropriate antiseptic solution per facility guidelines.

Choice C Reason:

Use a 10-mL syringe to flush the line. When completing discharge teaching for a client with a peripherally inserted central catheter (PICC) line, the nurse should include instructions regarding the proper care of the line. Using a 10-mL syringe to flush the line is the appropriate practice to prevent excessive pressure within the catheter and minimize the risk of catheter damage or rupture.

Choice D Reason:

Not elevating the arm above the level of the heart - Elevation of the arm above the heart level is generally not contraindicated for a PICC line. However, it's important to avoid activities that could lead to kinking or pulling on the line. The nurse should provide specific instructions regarding arm movement and care to the client.

A. Decreased bowel sounds B. increased central venous pressure C. Hyperreflexia D. Contusion

Correct Answer is B

Explanation

Choice A Reason:

Decreased bowel sounds: Hyponatremia (low serum sodium levels) primarily affects the nervous system and can lead to neurological symptoms such as confusion, seizures, and headache. It doesn't typically directly affect bowel sounds. Therefore, this option is not the expected finding.

Choice B Reason:

Increased central venous pressure: As I mentioned earlier, hyponatremia can lead to cerebral edema (swelling of the brain) due to the movement of water into cells. This swelling can increase intracranial pressure and, in turn, affect the central venous pressure by impacting blood return to the heart. While the relationship between hyponatremia and central venous pressure might be complex, it's a more relevant consideration compared to the other options provided.

Choice C Reason:

Hyperreflexia: Hyponatremia can lead to changes in brain function and neurological symptoms, including altered reflexes. Hyperreflexia, which is an exaggerated response to stimuli, can indeed be a manifestation of hyponatremia, making this option a potential expected finding.

Choice D Reason:

Contusion: A contusion is a bruise that results from damage to blood vessels beneath the skin. Hyponatremia is not directly related to the formation of contusions. This option is not the expected finding in a client with low serum sodium levels.

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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 is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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