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 client who has NPO (nothing by mouth) status since midnight for an endoscopy could be at risk for fluid volume deficit. NPO status means the client has not been able to consume fluids orally, which could lead to a decrease in fluid intake. However, the risk is relatively low if the NPO status has only been in place since midnight and the client is otherwise healthy.
Choice B rationale:
A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.
Choice C rationale:
A client who has gastroenteritis and is receiving oral fluids is not typically at risk for fluid volume deficit. Gastroenteritis can cause fluid loss through diarrhea and vomiting, but if the client is able to consume and retain oral fluids, they can usually maintain their fluid balance.
Choice D rationale:
A client who has end-stage kidney disease and will undergo dialysis could be at risk for fluid volume deficit, but this risk is typically well-managed during dialysis. Dialysis removes waste and excess fluid from the blood, and fluid intake is carefully monitored and adjusted based on the individual’s needs. Therefore, while there is a potential risk, it is usually well-controlled under the care of healthcare professionals.
Correct Answer is D
Explanation
Choice A rationale:
Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm is the correct procedure for a Mantoux tuberculin skin test.
Choice B rationale:
Visualizing the tip of the needle under the skin is the correct procedure for a Mantoux tuberculin skin test.
Choice C rationale:
Stretching the skin tightly before injection is the correct procedure for a Mantoux tuberculin skin test.
Choice D rationale:
Withdrawing the needle and massaging the site gently is incorrect. Massaging the site can cause the test solution to disperse, which can affect the test results.
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