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 ["A","B","C"]

Explanation

The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and

c. Check the drainage tubing for obstructions.

a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.

b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.

c. Checking the drainage tubing for obstructions is essential to ensure proper ﬂow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can aﬀect the eﬀectiveness of the procedure and potentially lead to complications.

d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.

e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.

By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.

A. Encourage the client to gain 2.3 kg (5 lb) per week. B. Monitor the client for 15 min after meals. C. Weigh the client each morning after voiding D. Reinforce teaching about healthy eating during meals

Correct Answer is C

Explanation

C. Weigh the client each morning after voiding: Weighing the client in the morning after voiding is the standard practice for monitoring weight in clients with anorexia nervosa. This helps ensure consistency in the measurement of weight, as fluctuations throughout the day (due to food, fluid intake, etc.) can affect the accuracy of weight assessment.

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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 caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Correct Answer is C

Explanation

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