A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has pneumonia and has an axillary temperature of 38° C (101° F)

A client who has diarrhea and requests clear liquids for breakfast

A client who has a cast on the left leg and reports numbness and paresthesia

A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150

Answer and Explanation

The Correct Answer is C

Rationale:

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.

B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.

C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.

D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.

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Correct Answer is A

Explanation

Rationale:

A. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.

B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.

C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.

D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.

A. Dilated pupils B. Euphoria C. Rhinorrhea D. Hallucinations

Correct Answer is B

Explanation

Rationale:

A. Dilated pupils are typically associated with stimulant use, not opioids.

B. Euphoria is a common effect of opioid use and can indicate misuse or diversion of these medications.

C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.

D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.

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A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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