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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.
B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.
C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.
D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.
Correct Answer is D
Explanation
Rationale:
A. A client who has a small circular partial-thickness burn of the left calf requires care, but this is less urgent compared to severe airway or respiratory issues.
B. A client who has a massive head injury and is experiencing seizures is critical but still less urgent compared to immediate life-threatening airway issues.
C. A client who has a splinted open fracture of left medial malleolus requires care but is not as immediately life-threatening as respiratory issues.
D. A client who has severe respiratory stridor and a deviated trachea has a life-threatening airway obstruction that needs immediate intervention to ensure adequate breathing and oxygenation.
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