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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)


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Related Questions

Correct Answer is A

Explanation

A. "Arrange to perform all nonessential tasks for the client at one time."
Grouping nonessential tasks reduces frequent disruptions, allowing the client to rest more effectively, which is essential for recovery.
B. "Encourage the client to sleep as much as possible during the day."
Excessive daytime sleeping can disrupt the client’s sleep-wake cycle, leading to difficulty sleeping at night.
C. "Perform routine hygiene for the client during the night."
Performing hygiene tasks at night can disturb the client’s rest and impact recovery.
D. "Remove limits on visiting hours for the client." Unrestricted visiting hours can increase noise and interruptions, making it harder for the client to get adequate rest.

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

Explanation

A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.

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