A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
A client who was administered acyclovir for cellulitis reports pain in the affected leg
A client who was administered adalimumab for Crohn’s disease, has a serum calcium level of 10 mg/dL, and reports a headache
A client who was administered erythromycin for acute glomerulonephritis and reports reddish brown urinary output
A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dl
The Correct Answer is D
A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.
B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.
C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.
D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pneumothorax: A pneumothorax occurs when air accumulates in the pleural space, causing the lung to collapse. It often presents with unilateral chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
B. Atelectasis: Atelectasis refers to the collapse of alveoli in the lungs, often caused by obstruction, compression, or lack of surfactant. Symptoms include hypoxemia, diminished breath sounds, and shortness of breath.
C. Hemothorax: A hemothorax occurs when blood accumulates in the pleural space. It typically presents with chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
D. Flail Chest: Flail chest results from multiple rib fractures that create a free-floating segment of the chest wall. This condition causes paradoxical chest movement, where the chest wall segment moves inward during inspiration and outward during expiration.
Correct Answer is ["100"]
Explanation
Clindamycin is an antibiotic that can treat infections caused by staphylococci bacteria. It can be given by intermittent IV bolus, which means injecting the drug into a vein over a short period of time. To calculate the infusion rate for clindamycin, we need to use the formula:
Infusion rate (ml/hr) = Volume (ml) / Time (hr)
In this case, the volume is 50 ml and the time is 0.5 hr (30 min). Plugging these values into the formula, we get:
Infusion rate (ml/hr) = 50 ml / 0.5 hr
Infusion rate (ml/hr) = 100 ml/hr
Therefore, the nurse should set the IV pump to deliver 100 ml/hr of clindamycin.
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