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 B
Explanation
The correct answer is choice B.
Choice A rationale:
A blood pressure of 108/60 mm Hg is considered normal, as it is less than 120/80 mm Hg.
Choice B rationale:
A blood pressure of 154/96 mm Hg falls into the category of stage 1 hypertension. Stage 1 hypertension is classified as a systolic blood pressure reading that falls between 130 and 139 mm Hg or a diastolic reading that is between 80 and 89 mm Hg.
Choice C rationale:
A blood pressure of 164/104 mm Hg is considered stage 2 hypertension, as the systolic blood pressure is 140 mm Hg or higher, or the diastolic pressure is 90 mm Hg or higher.
Choice D rationale:
A blood pressure of 128/88 mm Hg is considered elevated, as the systolic blood pressure ranges from 120 to 129 mm Hg and the diastolic blood pressure is below 80 mm Hg.
Correct Answer is B
Explanation
Choice A rationale:
Changing soiled linens daily is important, but it is not the most effective way to prevent the spread of pathogens.
Choice B rationale:
Hand hygiene is the single most effective way to prevent the spread of pathogens. It should be performed before and after every client interaction, before and after any procedure, and after any contact with potentially infectious material.
Choice C rationale:
Discarding used syringes in appropriate containers is important for safety, but it does not directly prevent the spread of pathogens.
Choice D rationale:
Properly disposing of contaminated equipment is important, but hand hygiene is more effective at preventing the spread of pathogens.
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