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.

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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.

A. Instructions on how to change ventilator settings B. Instructions on mouth care C. Instructions to suction the client’s tracheostomy every 2 hr D. Instructions to place the client in a supine position

Correct Answer is B

Explanation

A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.

B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.

C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.

D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Correct Answer is B

Explanation

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