A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

A decreased level of consciousness and vomiting

Cellulitis accompanied by a low-grade fever

A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago

Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL

Answer and Explanation

The Correct Answer is A

A.   A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B.   Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C.   A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D.   A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.

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Correct Answer is C

Explanation

A. While the blood pressure reading provides information about the client's cardiovascular status, it does not specifically indicate the severity of heart failure. Therefore, it is not the most pertinent information to include in the report.
B. The potassium level is important to monitor in clients with heart failure due to the potential for electrolyte imbalances, but a specific potassium level of 4.9 mg/dL may not be immediately relevant to the client's current status. Therefore, it is not the most critical information to include in the report.

C. Pitting edema in the lower extremities is a common finding in clients with heart failure and can indicate fluid overload, a hallmark characteristic of heart failure. Including this information in the report is essential for providing an accurate picture of the client's condition and current status.
D. While assistance with meals may provide insight into the client's functional status and support system, it is not as directly related to the client's heart failure as the presence of pitting edema.

A. "A nurse will insert an IV prior to starting the test." B. "You should have nothing to eat or drink for 4 hours prior to the test." C. "You should expect the test to take a minimum of 2 hours." D. "You will be asked to press a button when you feel your baby move." E. "You will be asked to press a button when you feel your baby move."

Correct Answer is D

Explanation

A. Inserting an IV is not necessary for a nonstress test, which is a noninvasive procedure.
B. Fasting is not required for a nonstress test, as it does not involve any invasive procedures.
C. C. A nonstress test typically takes around 20 to 30 minutes to complete, not a minimum of 2 hours.
D. This is the correct answer. During a nonstress test, the client is asked to press a button every time they feel their baby move. This helps correlate fetal movements with changes in fetal heart rate, providing information about fetal well-being.

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A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse include in the report?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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