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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fatigue is a common symptom of anemia, which can result from a low hemoglobin level.
Decreased oxygen-carrying capacity leads to feelings of tiredness.
B. Thickened fingernails are not typically associated with low hemoglobin levels. This symptom is more commonly seen in conditions such as fungal infections or psoriasis.
C. The need to go to the bathroom frequently is not directly related to low hemoglobin levels. It may be indicative of other conditions such as urinary tract infections or diabetes.
D. Shaky hands are not typically associated with low hemoglobin levels. This symptom may be seen in conditions such as essential tremor or Parkinson's disease.
Correct Answer is C
Explanation
A. While the blood pressure reading provides information about the client's cardiovascular status, it does not specifically indicate the severity of heart failure. Therefore, it is not the most pertinent information to include in the report.
B. The potassium level is important to monitor in clients with heart failure due to the potential for electrolyte imbalances, but a specific potassium level of 4.9 mg/dL may not be immediately relevant to the client's current status. Therefore, it is not the most critical information to include in the report.
C. Pitting edema in the lower extremities is a common finding in clients with heart failure and can indicate fluid overload, a hallmark characteristic of heart failure. Including this information in the report is essential for providing an accurate picture of the client's condition and current status.
D. While assistance with meals may provide insight into the client's functional status and support system, it is not as directly related to the client's heart failure as the presence of pitting edema.
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