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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Platelet count 90,000/mm3.
Explanation:
During pregnancy, it is important to monitor the client's platelet count because a low platelet count can indicate a condition called gestational thrombocytopenia or other potential complications such as preeclampsia or HELLP syndrome. A platelet count of 90,000/mm3 is lower than the normal range and should be reported to the provider for further evaluation and management.
Option a, Hgb 12 g/dL, falls within the normal range for hemoglobin during pregnancy, which is typically between 11-13.5 g/dL. Therefore, it does not require immediate notification to the provider.
Option c, Hematocrit 37%, also falls within the normal range for hematocrit during pregnancy, which is typically between 33-42%. Therefore, it does not require immediate notification to the provider.
Option d, Creatinine 0.7 mg/dL, is within the normal range for creatinine levels and does not indicate any immediate concerns or need for notification to the provider.
It is important to remember that the interpretation of laboratory results should be done in the context of the client's individual clinical presentation and the healthcare provider's assessment. Any concerns or abnormal findings should be communicated to the provider for further evaluation and appropriate management.
Correct Answer is C
Explanation
c. "I will have a chest x-ray following the procedure."
Explanation:
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
Explanation for the other options:
a. "I will have general anesthesia during the procedure":
This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
b. "I will lie flat for 6 hours following the procedure":
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
d. "I will breathe deeply through my nose during the procedure":
This statement is incorrect. During a thoracentesis, the client is typically asked to sit upright and lean forward to allow beter access to the space between the lungs and chest wall. They may be instructed to take slow, deep breaths and hold their breath for short periods as needed during the procedure to help maintain proper positioning and reduce the risk of complications.
In summary, the statement that demonstrates an understanding of the thoracentesis procedure is "I will have a chest x-ray following the procedure." This indicates the client's awareness of the need for a post- procedure chest x-ray to evaluate the results and ensure the absence of any complications.
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