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 A

Explanation

After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.

The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:

Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.

A. "I will increase my intake of meat and beans.” B. "I will take a Vitamin C supplement to increase iron absorption." C. “This anemia may occur more during pregnancy of menstruation."" D. I will increase my intake of dairy products. E. "Oral supplements are not as effective as monthly subcutaneous injections.”

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

Explanation

These statements reflect the appropriate knowledge related to iron deficiency anemia. Iron-rich foods such as meat and beans can help increase iron levels in the body. Vitamin C aids in the absorption of iron, so taking a Vitamin C supplement can enhance iron absorption. Iron deficiency anemia is more common during pregnancy or menstruation due to increased iron demands.

However, increasing intake of dairy products alone does not address the iron deficiency. The statement about oral supplements not being as effective as monthly subcutaneous injections is incorrect, as oral iron supplements are commonly used to treat iron deficiency anemia and are effective in most cases.

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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 nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

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The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency? SELECT ALL THAT APPLY

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

Explanation

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