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 C

Explanation

c. Periorbital edema.

Explanation: Acute glomerulonephritis is an inﬂammatory condition aﬀecting the glomeruli of the kidneys. It is commonly characterized by periorbital edema, which is swelling around the eyes. This occurs due to ﬂuid retention and impaired kidney function. Other common manifestations of acute glomerulonephritis include hypertension (increased blood pressure), dark or tea-colored urine (hematuria), decreased urine output, and signs of ﬂuid overload such as edema in the hands, feet, and face.

Option a, decreased blood pressure, is not typically seen in acute glomerulonephritis. Instead, hypertension is a common finding due to ﬂuid retention and increased blood volume.

Option b, pale yellow urine, is not expected in acute glomerulonephritis. Instead, urine may appear dark or

tea-colored due to the presence of blood (hematuria).

Option d, increased urination, is not a characteristic finding in acute glomerulonephritis. Instead, there is often a decrease in urine output or oliguria.

It is important to note that individual presentations may vary, and the nurse should consider the complete clinical picture and the child's specific symptoms when assessing for acute glomerulonephritis.

A. "You will need an annual TB skin test to see if the infection has returned." B. "You will take medication to treat your illness for the rest of your life." C. "You can expect the medications to turn your urine a blue-green color." D. "You are no longer contagious when you have negative sputum cultures."

Correct Answer is D

Explanation

When a client with active pulmonary tuberculosis (TB) receives appropriate treatment and their sputum cultures consistently show negative results for Mycobacterium tuberculosis, it indicates that the client is no longer contagious. Negative sputum cultures indicate that the infectious bacteria are no longer present or viable in the respiratory secretions, reducing the risk of transmitting the disease to others.

"You will need an annual TB skin test to see if the infection has returned": While it is important for individuals with a history of TB to undergo periodic screening, such as an annual TB skin test or interferon-gamma release assay (IGRA), to detect latent TB infection or potential reactivation, this response is not specifically related to a client with active pulmonary TB.

"You will take medication to treat your illness for the rest of your life": This response is incorrect because active pulmonary TB is typically treated with a combination of antimicrobial medications for a specific duration, usually ranging from 6 to 9 months. It is not a lifelong treatment.

However, individuals with latent TB infection may require longer-term treatment to prevent the development of active TB disease.

"You can expect the medications to turn your urine a blue-green color": This response is incorrect as medications used to treat TB do not typically cause urine discoloration. Medications such as rifampin can cause various side effects, including orange discoloration of bodily fluids like urine, tears, or sweat, but a blue-green color is not associated with TB medications.

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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 collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has active pulmonary tuberculosis. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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