A nurse is assigned to care for four clients. Which client should the nurse assess first?

A postoperative client preparing for discharge with a new medication.

A client requiring daily dressing changes of a recent surgical incision.

A client scheduled for a chest x-ray after insertion of a nasogastric tube.

A client with asthma who requested a nebulizer treatment during the previous shift.

Answer and Explanation

The Correct Answer is D

Choice A reason: While it is important to prepare the postoperative client for discharge and ensure they understand how to take their new medication, this situation is less urgent than addressing a potential respiratory issue.

Choice B reason: Changing the dressing on a recent surgical incision is part of routine care and can be scheduled after more urgent needs are addressed. The client’s wound care is important, but it does not take precedence over potential respiratory distress.

Choice C reason: Although the chest x-ray is necessary to confirm the correct placement of the nasogastric tube, this can be done after the more immediate concern of a respiratory issue is addressed. The nasogastric tube will remain in place for feeding or drainage in the meantime.

Choice D reason: This client should be assessed first because asthma can lead to respiratory distress or an asthma attack, which requires prompt intervention. Since the client requested a nebulizer treatment during the previous shift, it is crucial to assess their current respiratory status and administer the treatment if necessary to prevent any complications.

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Correct Answer is D

Explanation

Choice A reason: Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive.

Choice B reason: Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed.

Choice C reason: Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status.

Choice D reason: Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.

A. Heart rate of 104 bpm B. Tympanic temperature of 102.6°F (39.2°C) C. Blood pressure of 158/90 mmHg D. Respiratory rate of 24 breaths/min

Correct Answer is B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

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A nurse is assigned to care for four clients. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

Correct Answer is D

Explanation

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

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