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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Adequate hydration: Maintaining proper fluid intake helps reduce blood viscosity and prevents sickling of red blood cells. Dehydration is a common trigger for sickle cell crises, so emphasizing hydration is crucial for prevention.

B. Increased iron intake: Most clients with sickle cell anemia do not require additional iron unless they have documented iron deficiency. Excess iron can accumulate and cause complications, especially in those receiving frequent transfusions.

C. Calorie restriction: Restricting calories is not recommended, as children with sickle cell anemia often have increased metabolic needs due to chronic hemolysis and may require adequate nutrition for growth and energy.

D. A low-protein diet: Protein is important for growth, tissue repair, and overall health. A low-protein diet is not indicated and could worsen nutritional status in children with sickle cell disease.

A. "I recommend that you take this medication as prescribed." B. "I will call the pharmacist now to check on this medication." C. "Did the doctor discuss with you that there was a change in this medication?" D. "Do you know why this medication is being prescribed for you?"

Correct Answer is B

Explanation

Rationale:

A. "I recommend that you take this medication as prescribed.": This response dismisses the client’s concern and does not address the possibility of a medication error. It can also undermine trust and ignores the need for verification before administration.

B. "I will call the pharmacist now to check on this medication.": This is the most appropriate response because it prioritizes client safety by verifying the medication before administration. It also acknowledges the client’s concern and involves a qualified resource for confirmation.

C. "Did the doctor discuss with you that there was a change in this medication?": While this could provide insight into changes in therapy, it delays immediate verification and does not address the need to confirm the medication’s accuracy before giving it.

D. "Do you know why this medication is being prescribed for you?": This may promote client education, but it does not address the immediate safety concern or the need to verify the medication before administration.

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Which of the following clients should be considered a priority for immediate assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of which of the following factors to prevent a sickle cell crisis?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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