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 A

Explanation

A. Completing an incident report is crucial whenever an error occurs in patient care. This helps to ensure that the error is properly documented, investigated, and addressed to prevent recurrence and promote patient safety.
B. Allowing the incorrect solution to finish infusing could potentially harm the patient. Once the error is identified, the infusion should be stopped immediately, and corrective action should be taken.
C. Documenting that an error occurred in the client's medical record is important, but completing an incident report is a separate step that ensures a thorough investigation and response to the error.
D. Removing the IV catheter may be necessary if the infusion needs to be stopped, but it does not address the need to document and report the error to prevent future occurrences and ensure patient safety.

A. Allow the family as much time as they want with the client. B. Use paper tape to hold the client's eyelids open. C. Place the client in a supine position. D. Avoid repeating information about the client's death.

Correct Answer is A

Explanation

A. Allowing the family as much time as they want with the client is essential for them to process their emotions, say goodbye, and find closure. This respects their grieving process and allows
them to spend precious moments with their loved one.

B. Using paper tape to hold the client's eyelids open is not appropriate and may cause discomfort or distress to the family.

C. Placing the client in a supine position is unnecessary after death and may not contribute to the family's comfort.
D. Avoiding repeating information about the client's death is not advisable. The nurse should be available to provide clarification, answer questions, and offer support as needed.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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