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 D
Explanation
A. Decreased respirations: Moderate dehydration typically does not cause respiratory depression. Respiratory changes are more commonly associated with severe acid-base imbalances or advanced dehydration.
B. Polyuria: Dehydration leads to decreased fluid volume, which generally results in oliguria (reduced urine output) rather than polyuria. Increased urination is not an expected finding in moderate dehydration.
C. Bradycardia: Dehydration usually causes a compensatory increase in heart rate (tachycardia) to maintain cardiac output. Bradycardia is not typical unless there is a severe or underlying cardiac issue.
D. Orthostatic hypotension: Loss of fluid volume from diarrhea and vomiting can decrease circulating blood volume, leading to a drop in blood pressure upon standing. This is an expected cardiovascular manifestation of moderate dehydration in school-age children.
Correct Answer is C
Explanation
A. "I cannot be a witness for your consent to donate.": While a nurse often cannot witness the consent form to avoid a conflict of interest, this response does not directly address the client’s need for information about how to become an organ donor.
B. "Your name cannot be removed once you are listed on the organ donor list.": Clients can change their decision about organ donation at any time, and their name can be removed from the registry if they choose.
C. "Your desire to be an organ donor must be documented in writing.": Documenting consent in writing ensures legal clarity and verifies the client’s intent. Written consent is required to formalize organ donation in the medical record or donor registry.
D. "You must be at least 21 years of age to become an organ donor.": Age requirements for organ donation vary by jurisdiction, and many states allow individuals younger than 21 to register as donors, often with parental consent if under 18.
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