After receiving morning report about four clients, which client should the nurse attend to first?
An older female client who had a hip replacement yesterday and is notably pale with a Hemoglobin of 10.5 g/dl.
An adult client with osteomyelitis of the ankle who refuses an IV restart that is needed to administer antibiotics.
An elderly client with low back pain who removed the pelvic traction and repeatedly states a strong desire to go home.
A young adult client with a closed reduction of a fractured femur who has been complaining of increasingly severe pain.
The Correct Answer is D
Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.
Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.
Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.
Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.
Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.
Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.
Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.
Correct Answer is B
Explanation
Choice A: A high protein diet is generally not recommended for clients with glomerulonephritis, as it can put additional strain on the kidneys.
Choice B: In glomerulonephritis, there is impaired kidney function, and sodium and fluid restrictions are often necessary to manage fluid balance and blood pressure.
Therefore, the nurse should instruct the client to restrict sodium-rich foods and excessive oral fluids.
Choice C: A low carbohydrate diet with low glycemic index foods is not a specific dietary recommendation for managing glomerulonephritis.
Choice D: Dietary potassium restriction may vary depending on the individual client's potassium levels and needs, so it should be determined by the healthcare provider. It is not a blanket recommendation for all clients with glomerulonephritis.
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