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 is scheduled for a procedure in 1 hr
A client who received a pain medication 30 min ago for postoperative pain
A client who has 100 mL of fluid remaining in his IV bag
A client who was just given a glass of orange juice for a low blood glucose level
The Correct Answer is D
A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
- A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
- A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
- A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Bulging fontanels are not typically associated with withdrawal from maternal methadone use. They might indicate increased intracranial pressure or other conditions.
B. Correct. Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.
C. Incorrect. Bradycardia is not a common withdrawal symptom from maternal methadone use. Neonates withdrawing from opioids might experience tachycardia, not bradycardia.
D. Incorrect. Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to withdrawal from methadone. It can be related to immature peripheral circulation.
Correct Answer is A
Explanation
A. Correct. Infants with heart failure may tire easily during feedings, so limiting oral feedings to 30 minutes helps prevent excessive fatigue and ensures they are able to feed effectively without becoming overtired.
B. Incorrect. This is not frequent enough for an infant with heart failure. Oxygen saturation should be monitored more frequently, such as every 1-2 hours or as indicated by the clinical situation, to ensure adequate oxygenation and detect any changes promptly.
C. Incorrect. Weighing the infant daily is more appropriate to monitor fluid balance and heart failure progression.
D. Incorrect. Placing the infant in the prone position is contraindicated due to the risk of compromising respiratory function.
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