The nurse is caring for four different clients. Which of these clients should the nurse assess first?

The client who has a history of rheumatoid arthritis complaining of 5/10 pain in the joints of his hands.

The client who requires a chlorhexidine scrub prior to a double mastectomy this morning.

The client who can have nothing by mouth for a scheduled surgery this morning and received an ordered dose of insulin glargine the night before.

The client who is receiving digoxin with a blood pressure of 100/75 mmHg.

Answer and Explanation

The Correct Answer is D

a) Pain in a client with a history of rheumatoid arthritis is important but may not require immediate attention compared to potential complications of medication administration.

b) Preparing a client for a chlorhexidine scrub is important, but it is not an immediate priority compared to potential complications related to medication and vital signs.

c) A client who cannot have anything by mouth before surgery and received insulin glargine the night before needs monitoring, but it may not require immediate assessment compared to the potential complications of the client receiving digoxin with a blood pressure of 100/75 mmHg.

d) The client receiving digoxin with a blood pressure of 100/75 mmHg is at risk for toxicity, as low blood pressure may increase the concentration of digoxin. This client should be assessed first to prevent potential complications.

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Correct Answer is C

Explanation

a) Rising slowly from lying to sitting and standing is a precaution to prevent orthostatic hypotension, a potential side effect of calcium channel blockers.

b) Elevating legs if edema occurs is a reasonable response to manage peripheral edema associated with calcium channel blockers.

c) Grapefruit juice can interact with calcium channel blockers, leading to increased drug levels and potential toxicity. This statement indicates a need for additional teaching.

d) Increasing fluid and fiber to limit the risk of constipation is a reasonable measure associated with the use of calcium channel blockers.

A. Request central venous access. B. Continue the infusion while elevating the arm. C. Immediately stop the infusion and select an alternate intravenous site. D. Apply warm packs to the arm and infuse the medication at a slower rate.

Correct Answer is C

Explanation

a) Requesting central venous access is not the first-line response to signs of redness, pain, and irritation at the current infusion site. It's essential to address the immediate issue first.

b) Continuing the infusion while elevating the arm may exacerbate the symptoms and is not an appropriate action when there are signs of localized irritation.

c) Stopping the infusion and selecting an alternate intravenous site is the correct action to prevent further complications and assess the cause of the irritation.

d) Applying warm packs and infusing the medication at a slower rate may not be sufficient to address the observed redness and pain, and an alternate site should be considered.

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The nurse is caring for four different clients. Which of these clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these comments by a client taking a calcium channel blocker would indicate the need for additional teaching?

Correct Answer is C

Explanation

A client who is receiving a final dose of intravenous cephalosporin complains of pain and irritation at the infusion site. The nurse observes signs of redness at the intravenous insertion site and along the vein. What is the nurse's action?

Correct Answer is C

Explanation

A client with a new diagnosis of atrial fibrillation is receiving a continuous infusion of heparin. Which finding will the nurse report immediately?

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The nurse is caring for four different clients. Which of these clients should the nurse assess first?

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