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 A
Explanation
A. The erythrocyte sedimentation rate (ESR) is a marker of inflammation and is used to monitor the effectiveness of anti-inflammatory treatments such as aspirin in clients with rheumatoid arthritis.
B. Antinuclear antibody (ANA) is used to diagnose autoimmune diseases but is not typically monitored for the effectiveness of aspirin therapy in RA.
C. Rheumatoid factor (RF) is used for the diagnosis of RA, but it does not change significantly with treatment.
D. White blood cell (WBC) count is not a specific marker for monitoring the effectiveness of aspirin in treating RA.
Correct Answer is A
Explanation
Rationale:
A. Furosemide is a loop diuretic that helps to lower potassium levels, making it appropriate for a client with hyperkalemia (potassium level of 5.3 mEq/L).
B. Potassium iodide would further increase potassium levels, which is contraindicated in this situation.
C. Digoxin does not directly affect potassium levels and could be dangerous in the context of hyperkalemia.
D. Lisinopril is an ACE inhibitor that can increase potassium levels, which would not be appropriate for this client.
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