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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dark yellow urine and low urine output (25 mL/hr) may indicate dehydration or decreased fluid intake, so a fluid bolus is indicated to promote kidney perfusion.
B. Continuous bladder irrigation is typically indicated if there is concern about urinary tract obstruction or blood clots, not for low urine output alone.
C. Clamping the catheter can further hinder urine output and is not indicated.
D. A urine culture and sensitivity might be necessary if infection is suspected, but the priority is to address hydration first.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse anticipates the client will likely require proton pump inhibitors (PPIs) as evidenced by the client's reports of burning epigastric pain.
Rationale
Proton pump inhibitors (PPIs) are commonly prescribed for peptic ulcer disease to reduce stomach acid production, helping to heal the ulcer and alleviate pain. This intervention is anticipated if the client experiences epigastric pain.
Antibiotics would be prescribed if there is evidence of an H. pylori infection, which is a common cause of peptic ulcers.
Antacids can be used for symptom management, but they are typically a short-term measure rather than a primary treatment for healing ulcers
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