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

Explanation

Venous thromboembolism refers to the formation of blood clots in the veins, which can lead to serious complications such as pulmonary embolism. After surgery, immobility and reduced activity can increase the risk of developing blood clots. Therefore, it is crucial to prioritize measures to prevent venous thromboembolism, such as early mobilization, compression stockings, and anticoagulant medications, to ensure the patient's safety and well-being.

A. There are crackles throughout both lung fields. B. The patient's radial pulse is 105 beats/min. C. There is sediment and blood in the patient's urine D. The blood pressure increases from 66/50 to 122/74 mm

Correct Answer is A

Explanation

A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.

The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.

The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.

An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.

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

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Naxlex Comprehensive Predictor Exams

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