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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Free Nursing Study Resources

Correct Answer is A

Explanation

A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to

the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.

The other options are not correct.

b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.

c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.

d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.

A. "I will dispose of insulin needles in a puncture-proof container." B. "I will store opened insulin vials in my refrigerator." C. "I will shake the insulin vial before drawing it into the syringe." D. "I will expect my regular insulin to appear cloudy."

Correct Answer is A

Explanation

A client statement that indicates an understanding of discharge teaching for type 1 diabetes mellitus is "I will dispose of insulin needles in a puncture-proof container." This is the correct way to dispose of insulin needles to prevent accidental needle sticks.

The other options are not correct.

b) Opened insulin vials do not need to be stored in the refrigerator, but should be kept at room temperature.

c) Insulin vials should not be shakenas this can cause the insulin to break down.

d) Regular insulin should appear clear, not cloudy.

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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 admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use?

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a female client who has a new diagnosis of breast cancer. The client is concerned about potential changes to her body image depending on her choice of treatment. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?