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 B
Explanation
A. Both fontanels are the same size: Fontanels differ in size and shape; the anterior is larger and diamond-shaped, while the posterior is smaller and triangular. Expecting them to be the same size is inaccurate.
B. The anterior fontanel is open: The anterior fontanel typically remains open until about 12–18 months of age. At 8 months, an open anterior fontanel is an expected finding and indicates normal skull development.
C. The posterior fontanel is open: The posterior fontanel usually closes by 6–8 weeks of age. An open posterior fontanel at 8 months may indicate delayed closure and should be evaluated further.
D. Both fontanels show molding: Molding refers to overlapping of cranial bones during birth. At 8 months, molding should no longer be present; its presence is not a normal finding at this age.
Correct Answer is A
Explanation
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
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