The most appropriate response by the nurse is:

"Ice packs can be used to reduce swelling but should be removed after 20 minutes."

The nurse is caring for four clients. Which of these clients will the nurse see first?

A client with a urinary tract infection who has a fever of 38.5°C and flank pain

A client with a deep vein thrombosis who has a positive Homans' sign and edema in the affected leg

A client with a myocardial infarction who has chest pain and shortness of breath

A client with a stroke who has slurred speech and facial droop

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.

Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.

Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.

Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.

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Correct Answer is C

Explanation

Choice A reason: "I will take all prescribed medications." is not a statement that demonstrates an understanding of the teaching, because it is incomplete and vague. Taking all prescribed medications is an important part of the treatment for HIV, but it does not explain why, how, or for how long the medications are needed. Taking all prescribed medications without understanding the purpose, benefits, or risks can lead to poor adherence, compliance, or outcomes.

Choice B reason: "I will only need to take HIV medications for 6 months, and then I will be cured." is not a statement that demonstrates an understanding of the teaching, because it is incorrect and unrealistic. Taking HIV medications for 6 months is not enough to treat the infection, and there is no cure for HIV. HIV is a chronic and incurable infection that requires lifelong treatment with antiretroviral drugs, which can suppress the viral load, improve the immune function, and prevent the progression to AIDS. Stopping the medications after 6 months can cause the virus to rebound, the immune system to deteriorate, and the disease to worsen.

Choice C reason: "I will have to take medications for the rest of my life." is a statement that demonstrates an understanding of the teaching, because it is accurate and realistic. Taking medications for the rest of one's life is the reality of living with HIV, as there is no cure for the infection. Taking medications for the rest of one's life can help control the infection, maintain the health, and prolong the survival of people with HIV.

Choice D reason: "I will have to be careful and avoid crowds." is not a statement that demonstrates an understanding of the teaching, because it is unnecessary and exaggerated. Being careful and avoiding crowds is not a requirement for people with HIV, as the infection is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Being careful and avoiding crowds can also be detrimental to the social and emotional wellbeing of people with HIV, as it can cause isolation, stigma, or depression.

A. Call the chaplain for support B. Verify the reason for admission C. Request a medical interpreter D. Give the client a tour of the unit

Correct Answer is C

Explanation

Choice A reason: Calling the chaplain for support is not the priority nursing intervention for a client who speaks only Spanish. The chaplain may not be able to communicate with the client or understand their needs. This choice does not address the language barrier or the client's reason for admission.

Choice B reason: Verifying the reason for admission is an important nursing intervention, but it is not the priority for a client who speaks only Spanish. The nurse cannot verify the reason for admission without communicating with the client or their family. This choice does not address the language barrier or the client's safety.

Choice C reason: Requesting a medical interpreter is the priority nursing intervention for a client who speaks only Spanish. The medical interpreter can facilitate communication between the nurse and the client, and help the nurse assess the client's condition, reason for admission, and needs. This choice addresses the language barrier and the client's safety.

Choice D reason: Giving the client a tour of the unit is not the priority nursing intervention for a client who speaks only Spanish. The client may not understand the tour or the information given by the nurse. This choice does not address the language barrier or the client's reason for admission.

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The most appropriate response by the nurse is:"Ice packs can be used to reduce swelling but should be removed after 20 minutes."The nurse is caring for four clients. Which of these clients will the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements made by a client diagnosed with HIV demonstrates an understanding of the teaching?

Correct Answer is C

Explanation

A client arrives speaking only Spanish. What is the priority nursing intervention?

Correct Answer is C

Explanation

Which practice is recommended to prevent human immune deficiency virus (HIV) transmission?

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This is the edited text:The patient complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?

Which client is at the greatest risk for pressure injury development?

The most appropriate response by the nurse is:

"Ice packs can be used to reduce swelling but should be removed after 20 minutes."

The nurse is caring for four clients. Which of these clients will the nurse see first?