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 A
Answer is: A client who is scheduled for a procedure in 1 hr.
Explanation: The nurse should assess the client who is scheduled for a procedure in 1 hr first because this client may have a higher risk of complications or adverse outcomes from the procedure. The nurse should also monitor the client’s vital signs, pain level, and any signs of infection or bleeding before, during, and after the procedure. The nurse should also provide adequate preparation and education for the client regarding the procedure and its expected benefits and risks.
The other statements are wrong because:
- 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 may not need immediate assessment, unless there are signs of hypoglycemia or other complications. The nurse can check the client’s blood glucose level and provide appropriate treatment if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Polyhydramnios (excessive amniotic fluid) is not typically associated with placenta previa. It can be associated with conditions like fetal abnormalities or maternal diabetes.
B. Incorrect. Uterine tenderness might be present in conditions like uterine contractions, but it is not a primary finding in placenta previa.
C. Incorrect. Nausea is a common pregnancy symptom and is not directly related to placenta previa.
D. Correct. Spotting or painless vaginal bleeding is a hallmark sign of placenta previa, which occurs when the placenta covers part or all of the cervix. It can be life-threatening if severe bleeding occurs.
Correct Answer is C
Explanation
A. Incorrect. Leaving a nasogastric tube clamped after administering oral medication is a mistake, but it may not necessarily be considered malpractice if it doesn't result in harm or negligence.
B. Incorrect. Placing a yellow bracelet on a client at risk for falls is a safety measure, and it's not an example of malpractice.
C. Correct. Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.
D. Incorrect. Documenting communication with a provider in the progress notes of the client's medical record is a standard practice and not an example of malpractice.
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