After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

A client who has a history of pancreatitis and reports severe abdominal pain

A client who has heart failure and reports severe dyspnea

A client who is scheduled for abdominal surgery in 1 hr

A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Answer and Explanation

The Correct Answer is B

A.   While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B.   Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C.   While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D.   While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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Correct Answer is B

Explanation

A. The FACES scale is commonly used for children over 3 years of age who can understand and verbalize their pain using facial expressions.
B. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is appropriate for infants and young children who are unable to verbally communicate their pain. It assesses facial expression, leg movement, activity level, cry, and ability to be consoled.
C. The Color tool is not a recognized pain rating scale. It may be used to assess oxygenation in some cases but is not specific to pain assessment.

D. The Numeric scale involves asking the patient to rate their pain on a scale from 0 to 10 and is typically used with older children and adults who can understand and use numbers to describe
their pain intensity.

A. Ampicillin B. Erythromycin C. Cefazolin D. Clindamycin

Correct Answer is A

Explanation

A. Correct. Ampicillin is a penicillin antibiotic and is contraindicated in clients who are allergic to penicillin.
B. Incorrect. Erythromycin is not a penicillin antibiotic and can be an alternative for clients allergic to penicillin.
C. Incorrect. Cefazolin is a cephalosporin antibiotic and is not related to penicillin. It can be used as an alternative in clients allergic to penicillin.
D. Incorrect. Clindamycin is not related to penicillin and can be used as an alternative in clients allergic to penicillin.

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After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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