After a change-of-shift report, which client should the nurse assess first?

A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain

A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL

A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Answer and Explanation

The Correct Answer is B

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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Correct Answer is ["B","C","D","E"]

Explanation

The initial bundle of care in sepsis includes the following:

Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.

A. Coffee ground emesis, nausea/vomiting B. Right lower quadrant abdominal pain, constipation. C. Absent bowel sounds, abdominal pain D. Right upper quadrant abdominal pain, nausea/vomiting

Correct Answer is D

Explanation

Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.

Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.

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After a change-of-shift report, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

Which assessment findings will the nurse anticipate in the client with cholelithiasis?

Correct Answer is D

Explanation

A patient is admitted for treatment of Cushing's syndrome. The nurse correlates this disease process to which alteration in endocrine function?

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The nurse is providing education to a group of patients with pre-diabetes. The nurse will be sure to include which of the following in the education plan?