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 D

Explanation

The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.

A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.

The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.

A. a) Instruct the client to report the theft to the police. B. Report the possible abuse to adult protective services. C. Ask the client if there is another family member they can call for financial help. D. Restrict visitation for the client's family until discharge.

Correct Answer is B

Explanation

The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.

a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.

c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.

d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.

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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 providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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