How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a medical-surgical unit is caring for 6 clients.

Exhibits

Complete the following sentence by using the lists of options.

The first client the nurse should assess is

followed  by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

    1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
    2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
    3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

    1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
    2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
    3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

  1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
    2.  Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
    3.  Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
    4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
    5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
    6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

A. Plan to assign a different nurse to the client each shift. Assigning different nurses each shift disrupts continuity of care. Whenever possible, consistent nursing assignments improve client outcomes.
B. Start discharge planning on the day of admission. Discharge planning should begin upon admission to ensure a smooth transition of care, reduce hospital readmissions, and promote better long-term outcomes.
C. Request that the client complete a satisfaction survey at discharge. While client feedback is valuable, it does not directly contribute to continuity of care during the hospital stay.
D. Limit the number of interdisciplinary team members managing the client's care. Interdisciplinary collaboration (e.g., physicians, nurses, physical therapists, social workers) is crucial in providing comprehensive and continuous care, especially for complex cases.

Correct Answer is A

Explanation

A. Consider gender and age when selecting an interpreter Cultural preferences may influence comfort and communication. For example, a client may feel more comfortable speaking with an interpreter of the same gender or age group.
B. Direct comments and questions to the interpreter The nurse should speak directly to the client, not the interpreter, to maintain engagement and respect.
C. Speak to the client in a loud voice Speaking louder does not improve comprehension and may come off as disrespectful. Clear, slow speech is more effective.
D. Ask a member of the client's family to serve as an interpreter Family members may omit or alter information and are not trained in medical terminology or confidentiality laws. A professional medical interpreter should be used.

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

Register