A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?
A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode
A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800
A client who was admitted for chest pain and is reporting a new onset of indigestion
A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400
The Correct Answer is C
A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Traction weights are typically set by the physician and shouldn't be adjusted by the nurse unless specifically ordered.
B. Monitoring peripheral pulses helps assess circulation and neurovascular status in the affected extremity.
C. Examining the skin under the traction splint is essential to assess for skin integrity and prevent complications like pressure ulcers.
D. Assessing the temperature of the affected extremity helps detect signs of circulatory impairment or infection.
E. Positioning weights against the foot of the bed is not a correct action for managing Buck's traction.
Correct Answer is B
Explanation
A. Monitoring urine output is not specifically related to the side effects of ethambutol.
B. Ethambutol can cause optic neuritis, so monitoring visual acuity is essential.
C. Skin color changes are not commonly associated with ethambutol therapy.
D. Cardiac rhythm monitoring is not necessary for clients on ethambutol.
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