A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.
Choice B rationale
Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.
Choice C rationale
Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.
Choice D rationale
Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.
Correct Answer is D
Explanation
Choice A rationale
Cucumbers are a good source of hydration due to their high water content, but they are not particularly high in potassium.
Choice B rationale
Corn is a versatile vegetable that provides a good source of fiber, but it is not particularly high in potassium.
Choice C rationale
Asparagus is a nutrient-rich vegetable known for its diuretic properties, but it is not particularly high in potassium.
Choice D rationale
Avocados are a nutrient-dense fruit that is high in healthy fats and also a good source of potassium. They are a great food choice for a client at risk for hypokalemia.
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