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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. “Check your oxygen equipment once each week.”
Checking the oxygen equipment once a week is insufficient. The equipment should be regularly inspected for safety, including tubing, connections, and the condition of the oxygen concentrator or tank.

B. “Do not adjust the oxygen flow rate.”
The nurse should include in the teaching that the client should not adjust the oxygen flow rate without consulting their healthcare provider. Adjusting the oxygen flow rate without proper guidance can lead to inappropriate oxygen delivery, which may be harmful.

C. “Store unused oxygen tanks horizontally.”
Oxygen tanks should be stored in an upright position to prevent damage to the tank valve. Storing them horizontally can increase the risk of leaks or damage.

D. “Keep wool blankets on your bed.”
Wool blankets and other items that generate static electricity should be avoided near oxygen equipment, as they can increase the risk of fire. The client should be advised to use non-static bedding and clothing.

A. integrity of the dressing B. Need for suctioning C. Patency of the intravenous line D. Level of pain

Correct Answer is B

Explanation

A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.

B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.

C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.

D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client’s care?

Correct Answer is B

Explanation

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

A student is caring for a patient with positive end-expiratory pressure (PEEP) at 5 cm H20. The student asks “What is the purpose of PEEP?” which of the following is an appropriate response by the nurse?