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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
After a patient dies, postmortem care includes preparing them for family viewing. The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood settling in the face .
The other options are not correct because:
b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.
c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth
d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .
Correct Answer is A
Explanation
a ."I will take a stool softener to prevent constipation."
Explanation:
The statement that indicates an understanding of the instructions is "I will take a stool softener to prevent constipation."
Explanation for the other options:
b. "I will ask to work the night shift, so I will not be driving in bright sunlight."
This statement is incorrect. The need to work the night shift to avoid bright sunlight does not relate to the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The primary focus of discharge teaching for this condition would be related to eye care, medication administration, and follow-up appointments.
c. "I will need to use my eye drops for 1 year."
This statement is incorrect. While eye drops are commonly prescribed for open-angle glaucoma, the duration of their use can vary based on the individual's condition and the healthcare provider's instructions. The client should follow the specific instructions given by their healthcare provider regarding the frequency and duration of eye drop use.
d. "I will need to follow a low-protein diet."
This statement is incorrect. A low-protein diet is not typically part of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The focus of dietary recommendations for open-angle glaucoma is on maintaining a healthy diet and managing other health conditions that may affect intraocular pressure, such as high blood pressure or diabetes.
In summary, the statement that demonstrates an understanding of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma is "I will take a stool softener to prevent constipation." This indicates the client's awareness of the importance of preventing constipation, which can be a side effect of some medications prescribed after surgery.
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