A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.

Exhibits

Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

Client 1

Client 2

Client 3

Client 4

Client 5

Answer and Explanation

The Correct Answer is C

Choice A rationale: Client 1 is admitted with a new diagnosis of rheumatoid arthritis. While this condition can cause discomfort and requires management, it is a chronic condition that does not typically present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice B rationale: Client 2 has a history of hyperlipidemia and has been administered Atorvastatin 20 mg PO as prescribed. Hyperlipidemia is a chronic condition that requires ongoing management, but it does not typically present an immediate threat to the client’s health. The fact that the client has been administered their medication as prescribed suggests that their condition is currently being managed effectively. Therefore, while this client will need to be monitored to ensure that their medication continues to be effective, they are not the highest priority at this time.

Choice C rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client’s pain is not well controlled and could be a sign of complications. Therefore, immediate assessment is required. This client should be the nurse’s highest priority.

Choice D rationale: Client 4 is admitted with a new diagnosis of heart failure. Heart failure is a serious condition that can have life- threatening complications. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

Choice E rationale: Client 5 has a stage 2 pressure injury on the left heel. Pressure injuries can lead to serious complications, including infection and tissue necrosis. However, a stage 2 pressure injury is a relatively minor injury that is unlikely to present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their pressure injury, they are not the highest priority at this time.

Choice F rationale: Client 6 is admitted with a new diagnosis of diabetes mellitus. Diabetes is a chronic condition that requires ongoing management. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.

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Correct Answer is D

Explanation

Choice A rationale

Biofeedback is a mind-body technique that helps individuals gain control over bodily processes that are normally involuntary. It is not contraindicated for a client with herpes zoster.

Choice B rationale

Aloe is a plant-based product often used for its soothing and healing properties. It is not contraindicated for a client with herpes zoster.

Choice C rationale

Feverfew is a medicinal herb often used for its anti-inflammatory properties. It is not contraindicated for a client with herpes zoster.

Choice D rationale

Acupuncture involves the insertion of thin needles into specific points on the body. It is contraindicated for a client with herpes zoster because it could potentially open a portal on the skin’s surface, increasing the risk of further infection.

A. Implement airborne precautions. B. Prepare for possible intubation and mechanical ventilation. C. Monitor the client’s blood glucose levels frequently. D. Administer IV antibiotics as prescribed. E. Ensure strict hand hygiene before and after client contact. F. Increase fluid intake to help with sputum production. G. Prepare to assist with a chest tube insertion.

Correct Answer is ["B","C","D","E","F"]

Explanation

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.

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A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions. Exhibits Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with herpes zoster is inquiring about the use of complementary and alternative therapies for pain management.Which therapy should the nurse inform the client is contraindicated for their condition?

Correct Answer is D

Explanation

Correct Answer is ["B","C","D","E","F"]

Explanation

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A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.

Exhibits

Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below: