A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium (Tensilon) test.

A client with Bell's palsy who has an order for prednisone and acyclovir.

A client with Parkinson's disease who has hypokinetic dysarthria and a lack of facial expressions.

A client with multiple sclerosis who has bladder flaccidity and is retaining urine.

Answer and Explanation

The Correct Answer is A

A.   A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium test is likely experiencing a myasthenic crisis, which is a life-threatening condition that requires immediate attention. This client would be the priority because they may require rapid intervention to maintain airway and breathing.
B.   Bell's palsy is characterized by sudden onset of facial paralysis due to inflammation of the facial nerve. While Bell's palsy can be distressing for the client, it does not typically require urgent intervention unless there are complications such as corneal abrasion due to inability to close the eye.
C.   Parkinson's disease is a chronic neurodegenerative disorder characterized by motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. While this client requires ongoing assessment and care, the symptoms described do not typically indicate an acute or urgent need for intervention.
D.   A client with multiple sclerosis who has bladder flaccidity and is retaining urine needs assessment and intervention to prevent complications such as urinary tract infections or renal damage. However, this is not as immediately life-threatening as a myasthenic crisis.

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Correct Answer is C

Explanation

A. While assessing pedal pulses is important for circulation and can indicate peripheral vascular status, it is not the highest priority compared to assessing renal function in a client with TTP.
B. Nutritional status is important for overall health and recovery but is not immediately critical compared to assessing for acute complications such as kidney damage in TTP.
C. TTP can lead to kidney damage due to the formation of clots in the small blood vessels of the kidneys. This can result in decreased urine output or even acute kidney injury (AKI). Monitoring urine output is crucial to assess renal function and detect early signs of kidney involvement.
D. TTP primarily affects the kidneys and blood coagulation system, leading to hemolysis and thrombocytopenia. Liver function is not typically a primary concern in TTP unless there are concurrent issues or complications.

A. "Use this inhaler as the first-line medication to relieve acute symptoms." B. "Inspect your mouth daily for signs of thrush." C. "Check your heart rate before each dose." D. "Skip the morning dose if you do not have any symptoms."

Correct Answer is B

Explanation

A. Fluticasone is an inhaled corticosteroid used primarily for maintenance therapy in COPD and asthma. It helps reduce airway inflammation and prevent exacerbations but is not used for immediate relief of acute symptoms such as bronchospasm or sudden shortness of breath.
B. Fluticasone, like other corticosteroids delivered by inhalation, can increase the risk of oral thrush (candidiasis) due to its local immunosuppressive effects in the mouth. It's important for clients to monitor their oral cavity regularly for signs such as white patches or soreness. Including this instruction is crucial to detect thrush early so that appropriate treatment can be initiated if necessary.
C. Monitoring heart rate is not specifically necessary before each dose of fluticasone. Fluticasone is not known to cause significant cardiovascular effects such as changes in heart rate. Heart rate monitoring may be more relevant for medications that can affect cardiovascular function or in clients with pre- existing cardiac conditions.

D. Fluticasone should be used regularly as prescribed for maintenance therapy to control airway inflammation and prevent exacerbations in COPD. Skipping doses, even if symptoms are not present, can lead to inadequate control of the disease and potential worsening of symptoms over time.

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A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives report on a client who is diagnosed with thrombotic thrombocytopenic purpura (TTP). Understanding the complications associated with this condition, which assessment is the priority for the nurse to complete for this client?

Correct Answer is C

Explanation

A nurse is providing education to a client who has chronic obstructive pulmonary disease and will begin using fluticasone by metered dose inhaler every 12 hours for maintenance. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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A nurse is providing education to a client who has chronic obstructive pulmonary disease and will begin using fluticasone by metered dose inhaler every 12 hours for maintenance. Which of the following instructions should the nurse include?

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The nurse is reviewing the results of the client's echocardiogram and notes that the ejection fraction is 35%. The nurse anticipates that which of the following medications will be ordered to increase the client's cardiac output?

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