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. Constipation is not a common or expected side effect of cefazolin and is not typically associated with this medication.
B. Elevated skin patches are not a known side effect of cefazolin and would not typically occur as a result of taking this medication.
C. Ringing in the ears (tinnitus) is a potential adverse effect of cefazolin and should be reported to the provider because it may indicate ototoxicity, which can be serious.
D. Depression is not a common side effect of cefazolin and is not typically associated with this medication.

A. Provide a tour of the perioperative area prior to surgery. B. Explain that anesthesia is a special type of sleep. C. Wait until after surgery to explain the importance of coughing and deep breathing. D. Keep medical equipment out of the client's sight.

Correct Answer is A

Explanation

A. Providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control over the situation.
B. Explaining that anesthesia is a special type of sleep is oversimplifying and may not provide the adolescent with a clear understanding of the procedure. It's important to provide accurate information at a developmentally appropriate level.
C. Waiting until after surgery to explain the importance of coughing and deep breathing misses an opportunity for preoperative education. Teaching about postoperative care beforehand allows the adolescent to understand and participate in their own recovery process.
D. Keeping medical equipment out of the client's sight may reduce anxiety, but it does not address the adolescent's need for preparation and education about the surgical experience.

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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

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct Answer is C

Explanation

A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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