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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Prophylactic antibiotics are not routinely given solely because of hemophilia A. They may be indicated based on the client's overall health and the procedure.
B. Packed RBCs are not typically needed for wisdom teeth extractions in clients with hemophilia A, as these procedures do not usually cause significant blood loss.
C. Recombinant factor VIII is the specific treatment for hemophilia A and is administered prior to procedures to prevent bleeding.
D. Fresh frozen plasma contains clotting factors but is not the treatment of choice for hemophilia A. Recombinant factor VIII is preferred due to its specific action and lower risk of complications.

A. (Select all that apply.) B. Low back pain C. Urine color D. Blood pressure E. Respiratory rate

Correct Answer is ["C","D"]

Explanation

A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

Correct Answer is C

Explanation

36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Correct Answer is ["C","D"]

Explanation

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

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A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

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A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?

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