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

Cellulitis accompanied by a low-grade fever

A decreased level of consciousness and vomiting

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 B

b. A decreased level of consciousness and vomiting

Explanation:

When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.

Explanation for the other options:

a. Cellulitis accompanied by a low-grade fever:

While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.

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

Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.

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

While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.

In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.

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Correct Answer is B

Explanation

The instruction that the nurse should include is "You can take a shower 1 day after your procedure." According to the Cleveland Clinic, the morning after the procedure, the client may take the dressing oﬀ the catheter insertion site. The easiest way to do this is when showering, get the tape and dressing wet and remove it.

Option a is incorrect because there is no information suggesting that a client must wait 3 days before resuming a regular diet after a cardiac catheterization.

Option c is incorrect because according to the Cleveland Clinic, clients should gradually increase their activities until they reach their normal activity level within one week after the procedure.

Option d is incorrect because there is no information suggesting that a client must wait 1 week before returning to school after cardiac catheterization.

A. The client's blood pressure has been reduced. B. The client exhibits diaphoresis C. The client is not grimacing D. The client has an elevated heart rate

Correct Answer is C

Explanation

Answer: (C) The client is not grimacing

Rationale:

A) The client's blood pressure has been reduced:

While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.

B) The client exhibits diaphoresis:

Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.

C) The client is not grimacing:

The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.

D) The client has an elevated heart rate:

An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.

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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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