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 to be discharged at 11:00.
A client who is ambulatory and going for an x-ray at 10:00.
The Correct Answer is A
Choice A rationale:
A client who is short of breath is experiencing a life-threatening situation and should be seen first.
Choice B rationale:
A client who received pain medication 30 min ago is likely to be comfortable and can be seen later.
Choice C rationale:
A client who is to be discharged at 11:00 can be seen closer to the discharge time.
Choice D rationale:
A client who is ambulatory and going for an x-ray at 10:00 can be seen after the x-ray.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Asking the client’s full name and date of birth is the most reliable method of identification.
Choice B rationale:
Verifying the client’s room number is not reliable because room assignments can change.
Choice C rationale:
Asking a family member to verify the client’s identity is not always possible or reliable.
Choice D rationale:
Checking the client’s name on the medication administration record (MAR) is important but should be done in conjunction with direct client identification.
Correct Answer is B
Explanation
Choice A rationale:
While calling 911 is important, it is not the first action the nurse should take. The nurse should first assess the victim’s condition.
Choice B rationale:
The first action when someone is choking is to ask if they can speak. If they can speak, it means air is still passing through the windpipe.
Choice C rationale:
The jaw-thrust maneuver is used to open the airway in an unconscious victim, not in a choking victim.
Choice D rationale:
Abdominal thrusts (Heimlich maneuver) are used when the victim cannot speak, indicating a complete airway obstruction.
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