A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who received a pain medication 30 min ago for postoperative pain

A client who was just given a glass of orange juice for a low blood glucose level

A client who has 100 mL of fluid remaining in his IV bag

A client who is scheduled for a procedure in 1 hr

Answer and Explanation

The Correct Answer is B

A.   A client who has recently received pain medication should be assessed for effectiveness but is not in immediate danger.
B.   A client who received orange juice for a low blood glucose level needs to be assessed for a return to normal glucose levels as hypoglycemia is a priority concern.
C.   A client with 100 mL of fluid remaining in the IV bag can wait for assessment as their fluid needs can be managed once the infusion is complete.
D.   A client scheduled for a procedure in 1 hour is important to assess, but their immediate clinical needs may be less critical than a client with hypoglycemia.

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Correct Answer is D

Explanation

A. While furosemide helps reduce fluid overload, it does not directly decrease inflammation.
B. Furosemide does not specifically address pain; its primary purpose is to reduce fluid overload.
C. Furosemide should reduce blood pressure if fluid volume excess was contributing to the elevated blood pressure. If blood pressure increases, this would not be considered an effective response to the medication.
D. Weight loss is a common indicator of the effectiveness of diuretics like furosemide, as it helps to reduce the excess fluid volume in the body.

A. Provide humidification of the room air. B. Suggest rinsing his mouth with an alcohol-based mouth wash. C. Instruct the client on the use of esophageal speech. D. Offer the client saltine crackers between meals.

Correct Answer is A

Explanation

A. Providing humidification can help alleviate dry mouth by increasing moisture in the air, which is beneficial for the client experiencing xerostomia.
B. Alcohol-based mouthwash can exacerbate dry mouth and should be avoided.
C. Esophageal speech is typically used for clients who have had laryngectomy, not for those with xerostomia.
D. Saltine crackers are dry and could worsen xerostomia by further drying the mouth. Hydration and saliva substitutes are more appropriate.

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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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