A nurse has received report on four clients. What client should the nurse see first?

A client with a fasting blood sugar of 187.

A client with expiratory wheezing after an albuterol treatment.

A client who has been called to surgery 2 hours early.

A client with a blood pressure of 178/90 and needs a dose of atenolol.

Answer and Explanation

The Correct Answer is B

A client with expiratory wheezing after an albuterol treatment.

This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.

The client needs immediate intervention to improve airway patency and oxygenation.

Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.

The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.

Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.

The client can wait until the nurse has assessed the other clients.

Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.

The client needs a dose of atenolol, which is a beta

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Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

A. Cilia lining the respiratory tract sweep debris upward in mucus to be swallowed. B. The respiratory tract cools and dries the air being inhaled. C. Cells in the respiratory tract secrete lysozymes that can destroy certain bacteria. D. Macrophages engulf and destroy bacteria found in the alveoli. E. High concentration of oxygen and carbon dioxide aid the defense mechanisms.

Correct Answer is ["A","C","D"]

Explanation

These are natural respiratory defense mechanisms that help defend against infection.

Choice A is correct because cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.

This prevents pathogens and particles from reaching the lungs.

Choice B is wrong because the respiratory tract does not cool and dry the air being inhaled. In fact, the respiratory tract warms and humidifies the air to facilitate gas exchange.

Choice C is correct because cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.

Lysozymes are enzymes that break down the cell walls of bacteria.

Choice D is correct because macrophages engulf and destroy bacteria found in the alveoli. Macrophages are a type of white blood cell that act as scavengers of foreign invaders.

Choice E is wrong because high concentrations of oxygen and carbon dioxide do not aid the defense mechanisms.

On the contrary, high levels of these gases can impair gas exchange and cause acid-base imbalance.

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A nurse has received report on four clients. What client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

The nurse is caring for a client at risk for a respiratory infection. Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).

Correct Answer is ["A","C","D"]

Explanation

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