In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?
The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage.
The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine.
The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C).
The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.
The Correct Answer is A
Choice A Reason: This client has a potential airway obstruction and needs close monitoring by the nurse. Laryngeal nerve damage can cause vocal cord paralysis, which can lead to respiratory distress and aspiration.
Choice B Reason: This client needs education on the medication and its side effects, but this can be done by the PN under the supervision of the nurse. Levothyroxine is a synthetic thyroid hormone that replaces deficient hormones in hypothyroidism.
Choice C Reason: This client needs ongoing management of diabetes, but this can be done by the PN under the supervision of the nurse. Glycosylated Hgb (Hgb A1C) is a measure of the average blood glucose level over the past three months.
Choice D Reason: This client has a life-threatening condition that requires immediate treatment with corticosteroids, but this can be done by the PN under the supervision of the nurse. Addison's crisis is a severe form of adrenal insufficiency that causes hypotension, shock, and electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This client has a potential airway obstruction and needs close monitoring by the nurse. Laryngeal nerve damage can cause vocal cord paralysis, which can lead to respiratory distress and aspiration.
Choice B Reason: This client needs education on the medication and its side effects, but this can be done by the PN under the supervision of the nurse. Levothyroxine is a synthetic thyroid hormone that replaces deficient hormones in hypothyroidism.
Choice C Reason: This client needs ongoing management of diabetes, but this can be done by the PN under the supervision of the nurse. Glycosylated Hgb (Hgb A1C) is a measure of the average blood glucose level over the past three months.
Choice D Reason: This client has a life-threatening condition that requires immediate treatment with corticosteroids, but this can be done by the PN under the supervision of the nurse. Addison's crisis is a severe form of adrenal insufficiency that causes hypotension, shock, and electrolyte imbalance.
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.
Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.
Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.
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