The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?

Assess the level of consciousness and vital signs for both clients.

Review the plan of care and the medications that are due for both clients.

Complete a head-to-toe assessment of the client with pneumonia.

Change the surgical dressing to observe the appearance of the incision.

Answer and Explanation

The Correct Answer is A

A. Assess the level of consciousness and vital signs for both clients: Assessing vital signs and mental status identifies immediate changes in condition, particularly in critically ill clients. This is a priority because it helps detect life-threatening complications early.

B. Review the plan of care and the medications that are due for both clients: While important for planning interventions, reviewing the plan does not address immediate client safety and physiological status, which takes priority.

C. Complete a head-to-toe assessment of the client with pneumonia: A comprehensive assessment is valuable, but initial priority is rapid evaluation of vital signs and consciousness to identify urgent issues in the mechanically ventilated client.

D. Change the surgical dressing to observe the appearance of the incision: Dressing changes are important for infection prevention, but they are not emergent unless there are signs of acute bleeding or infection. Immediate physiologic assessment takes precedence.

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Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.

B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.

C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.

D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.

A. Before going to bed. B. During acute illness. C. Prior to exercising. D. Immediately after meals.

Correct Answer is B

Explanation

A. Before going to bed: Bedtime glucose checks may be recommended for some clients, especially those on insulin, but this timing is individualized. It is not universally required for every client with diabetes.

B. During acute illness: Any client with diabetes, regardless of age or type, should monitor glucose closely during acute illness. Illness can cause stress-induced hyperglycemia or unpredictable fluctuations, requiring more frequent testing to guide management.

C. Prior to exercising: Checking glucose before exercise is important for clients at risk of hypoglycemia, especially those using insulin or certain oral agents. However, this is not necessary for all clients, particularly those with type 2 diabetes controlled by diet alone.

D. Immediately after meals: Postprandial monitoring is useful in some cases to evaluate mealtime insulin effectiveness or dietary impact, but it is not universally recommended for every diabetic client. Its use depends on individualized treatment plans.

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The nurse working in a critical care unit (CCU) is assigned the care of two clients, one with pneumonia who is being mechanically ventilated, and the other who had a thoracotomy yesterday and is reporting incisional pain. Which action(s) should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Correct Answer is B

Explanation

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