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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer scheduled pain medications is appropriate because providing comfort is a priority in end-of-life care. Administering scheduled pain medications helps alleviate any discomfort or pain the client may be experiencing.
B. Providing oral care every 6 hr may not be necessary in the end-of-life stage, as the client's ability to tolerate oral care may decrease, and excessive oral care may cause discomfort.
C. Administering liquids using a syringe may not be appropriate if the client is unable to swallow or if there are concerns about aspiration.
D. Whispering when talking to family members is not necessary; instead, the nurse should communicate in a calm and clear manner, adjusting the volume and tone as needed to accommodate the client's condition and preferences.
Correct Answer is A
Explanation
A. "I will take a stool softener to prevent constipation." This is correct. Postoperative clients, especially those who are on opioid medications for pain management, are at risk for constipation. Taking a stool softener is a good strategy to prevent this complication after surgery.
B. "I will ask to work the night shift, so I will not be driving in bright sunlight." This is incorrect. Following laser surgery for open-angle glaucoma, clients are typically advised to avoid bright lights and glare, but there is no need to change work schedules. The focus should be on wearing protective sunglasses to shield the eyes from sunlight and glare, not on avoiding daytime work hours.
C. "I will need to use my eye drops for 1 year." This is incorrect. While eye drops may be prescribed to manage intraocular pressure, the duration of use will depend on the specific medication and the client's condition. It is not typically necessary to use them for an entire year after laser surgery, and the client should follow the provider's instructions for tapering or stopping the medication as indicated.
D. "I will need to follow a low-protein diet." This is incorrect. There is no specific dietary restriction for a low-protein diet following laser surgery for open-angle glaucoma. The client should follow a balanced diet as recommended by the healthcare provider.
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