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 A
Explanation
A. Correct. Malaise, which is a general feeling of discomfort or unease, is a common manifestation of bacterial pneumonia in children.
B. Tinnitus (ringing in the ears) is not a common manifestation of bacterial pneumonia.
C. Rhinorrhea (runny nose) is not typically associated with bacterial pneumonia; it is more commonly seen in viral respiratory infections.
D. Drooling is not a common manifestation of bacterial pneumonia.
Correct Answer is D
Explanation
A. Nonreactive pupils are not typically associated with pseudoparkinsonism.
B. Smacking lips is not typically associated with pseudoparkinsonism.
C. Serpentine limb movement is not typically associated with pseudoparkinsonism.
D. Correct. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol. It is characterized by motor symptoms similar to Parkinson's disease, including a shuffling gait, rigidity, bradykinesia (slowed movement), and resting tremor.
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