A nurse at a community health clinic is caring for a patient who reports a headache and stiff neck. Which of the following actions should the nurse take first?
Check the patient's blood temperature.
Administer an oral analgesic.
Perform a complete blood count.
Evaluate the patient's neurological status.
The Correct Answer is A
A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.
B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).
C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.
D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Blood verification must be done by two licensed nurses.
B. Incorrect. Monitoring for transfusion reactions is the nurse's responsibility.
C. Correct. UAPs can obtain baseline vital signs before the transfusion, as long as the nurse interprets them.
D. Incorrect. Verifying patient ID for blood transfusions is a nursing responsibility per hospital protocol.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
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