Which of the following clients should be considered a priority for immediate assessment and intervention?
A client who has epidural analgesia and weakness in the lower extremities
A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%).
A client who has sinus arrhythmia and is receiving cardiac monitoring.
A client who has a hip fracture and a new onset of tachypnea.
The Correct Answer is D
A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.
B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.
C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.
D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.
B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.
C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.
D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.
Correct Answer is D
Explanation
Rationale:
A. Case manager: A case manager coordinates overall care and resources for clients but does not provide direct interventions to improve fine motor skills affected by neuropathy.
B. Physical therapist: Physical therapy focuses on improving gross motor function, strength, balance, and mobility, rather than fine motor activities like buttoning clothes.
C. Social worker: Social workers assist with psychosocial support, community resources, and counseling, but they do not address functional limitations caused by neuropathy.
D. Occupational therapist: Occupational therapy specializes in helping clients perform activities of daily living (ADLs) and can provide adaptive techniques or devices to improve fine motor function, such as buttoning clothes, which is appropriate for this client’s needs.
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