A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who is short of breath
A client who received pain medication 30 min ago
A client who is ambulatory and going for an x-ray at 1000
A client who is to be discharged at 1100
The Correct Answer is A
A. Shortness of breath can indicate a serious respiratory issue, and this client may require immediate assessment and intervention. Respiratory distress can rapidly deteriorate a patient’s condition, making it essential to address this situation first.
B. While monitoring for pain relief and potential side effects is important, this client does not present an immediate threat to their health compared to the client experiencing shortness of breath. This client can be assessed after the more urgent cases.
C. Since the client is ambulatory and scheduled for an x-ray later, they can be seen after more critical needs have been addressed. Their situation is stable at this time.
D. While the discharge process is important, it can typically wait until more urgent situations are addressed. The nurse can prepare for the discharge but should focus on clients who have immediate health concerns first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While 10 mm indicates a significant reaction, the test should be read 48 to 72 hours post-injection for an accurate assessment.
B. Not positive: A 2-mm induration is generally considered negative, even in high-risk populations.
C. Not positive: A 3-mm induration does not meet the criteria for a positive reading in any population.
D. A 5-mm induration is significant in certain populations, especially for those at higher risk (e.g., immunocompromised individuals). In the context of the general population, a reading of 5 mm can be considered positive.
Correct Answer is ["A","D","E"]
Explanation
A. A barrel chest is a common finding in emphysema due to the hyperinflation of the lungs, which causes the chest to become rounded and increase in anterior-posterior diameter.
B. While clubbing can occur in some chronic respiratory conditions (like cystic fibrosis or lung cancer), it is not a common finding in emphysema. Therefore, this finding is not expected in this condition.
C. Emphysema is more likely to lead to tachycardia (increased heart rate) due to the body’s response to chronic hypoxia and the increased work of breathing. Bradycardia would not typically be associated with emphysema.
D. Dyspnea (difficulty breathing) is a hallmark symptom of emphysema. Patients often experience progressive shortness of breath, especially with exertion.
E. Patients with emphysema may exhibit shallow respirations due to the destruction of lung tissue and the resulting difficulty in fully expanding the lungs. They may adopt a breathing pattern that minimizes the work of breathing.
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