A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
Reference Range:
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl (10.8 mmol/L).
The client with an Ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
The Correct Answer is D
Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.
Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.
Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.
Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.
Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.
Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.
Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.
Correct Answer is D
Explanation
Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.
Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.
Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.
Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.
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