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 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.
The Correct Answer is C
This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.
The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
Choice B is wrong because a client who received pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.
Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.
Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Fish is a good source of protein and omega-3 fatty acids, which can help lower blood pressure, reduce inflammation, and prevent blood clots. Fish is also low in sodium, which is important for people with hypertension, as excess sodium can raise blood pressure by retaining fluid in the body. Fish is part of the DASH diet, which stands for Dietary Approaches to Stop Hypertension, and is a healthy eating plan that emphasizes fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, and lean meats.
Choice A. Cheese is wrong because cheese is high in sodium and saturated fat, which can increase blood pressure and cholesterol levels.
Cheese should be limited or avoided by people with hypertension.
Choice C. Red meat is wrong because red meat is also high in sodium and saturated fat, as well as cholesterol, which can contribute to hypertension and heart disease.
Red meat should be eaten sparingly or replaced by leaner sources of protein like fish, poultry, or beans.
Choice D. Canned black beans are wrong because canned black beans are high in sodium, as most canned foods are preserved with salt. Canned black beans should be rinsed well before eating or replaced by dried or cooked black beans, which are lower in sodium and high in fiber, potassium, magnesium, and calcium, which are beneficial for blood pressure control.
Correct Answer is ["C","E"]
Explanation
A urine culture is indicated for the client who has lower back pain and pinkish vaginal discharge, as these symptoms may suggest a urinary tract infection (UTI). A urine culture can identify the causative organism and guide the appropriate antibiotic therapy.
Phenazopyridine is a urinary analgesic that can relieve pain, burning, and urgency associated with a UTI. However, it requires a provider prescription and should not be used for more than two days.
A vaginal culture is not necessary for this client, as the vaginal discharge is likely due to the cervical changes during labor. A vaginal culture may be indicated for clients who have signs of vaginitis, such as itching, odor, or abnormal color of the discharge.
Obtaining a provider prescription for antibiotics is premature for this client, as the urine culture results are not available yet. Antibiotics should be prescribed based on the sensitivity of the organism causing the UTI.
Ibuprofen 600 mg every 6 hr for mild to moderate pain is not appropriate for this client, as it may interfere with uterine contractions and prolong labor. Ibuprofen is also contraindicated in the third trimester of pregnancy due to the risk of premature closure of the ductus arteriosus in the fetus. The nurse should use nonpharmacological methods to relieve the client’s back pain, such as massage, heat, or position changes.
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