A nurse is assigned to four clients when arriving for the day shift. Which client should the nurse prioritize for assessment?

A client who had an appendectomy and is receiving morphine sulfate and complains of nausea and pruritus

A client with a urinary tract infection who is receiving intravenous antibiotics and has gross hematuria

A client who received a loop diuretic for congestive heart failure and now complains of orthostatic symptoms.

A client with gastroenteritis who has had emesis for 21 hours and now complains of muscle pain and weakness.

Answer and Explanation

The Correct Answer is D

Gastroenteritis causes inflammatory gastrointestinal infection leading to vomiting and fluid loss causing electrolyte depletion such as hypokalemia, metabolic alkalosis, hypovolemia, neuromuscular weakness, and potential cardiac dysrhythmias due to potassium imbalance.

Rationale:

A. This client demonstrates opioid induced nausea and pruritus secondary to morphine sulfate histamine release and chemoreceptor stimulation. Postoperative appendectomy status is stable. Symptoms are expected adverse effects without airway compromise or hemodynamic instability requiring immediate priority assessment clinical care needed.

B. UTI with gross hematuria may indicate mucosal irritation or hemorrhagic cystitis but stable on IV antibiotics. No signs of shock or severe hemodynamic compromise are reported. Priority lower compared to acute electrolyte imbalance or neurological deterioration at this time now.

C. Orthostatic symptoms following loop diuretic administration suggest intravascular volume depletion and possible hypotension related to natriuresis. Client is at increased risk for falls and electrolyte imbalance, but condition remains less immediately life threatening than severe dehydration or arrhythmia risk states.

D. Prolonged emesis for 21 hours with gastroenteritis leads to significant fluid and electrolyte loss, particularly potassium depletion resulting in muscle weakness and potential cardiac dysrhythmias. This represents high priority due to risk of hypovolemia, metabolic alkalosis, and neuromuscular impairment state.

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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Hypertension is a chronic cardiovascular disorder characterized by persistently elevated systemic vascular resistance, impaired renal sodium excretion, and dysregulated renin-angiotensin-aldosterone system, leading to endothelial injury, left ventricular hypertrophy, and increased risk of stroke and myocardial infarction.

Rationale:

A. Vegetables such as spinach and peas are naturally low in sodium and high in potassium content, which supports vasodilation and blood pressure reduction. These foods are appropriate within a sodium-restricted dietary plan. They also improve vascular compliance and reduce peripheral resistance in hypertension management.

B. Canned soup typically contains high levels of sodium preservatives used for flavor enhancement and shelf stability. Avoiding processed soups demonstrates understanding of dietary sodium restriction. Choosing fresh alternatives reduces fluid retention and decreases intravascular volume, which is essential in blood pressure control.

C. Mashed cauliflower and boiled chicken are appropriate low-sodium meal options due to minimal added sodium content. Cauliflower serves as a low-carbohydrate substitute for starchy foods. Boiled chicken without seasoning avoids sodium overload and supports dietary compliance in hypertension management.

D. Spam is a processed meat product with extremely high sodium concentration used for preservation. Combined with eggs, it still significantly exceeds recommended sodium intake. This choice demonstrates misunderstanding of dietary restrictions and increases risk of fluid retention and elevated blood pressure.

E. Pickles undergo curing in brine solution, resulting in very high sodium content despite originating from cucumbers. This preservation method significantly increases sodium load. This statement reflects incorrect understanding of food processing and its impact on hypertension dietary management.

A. Ensure that only a nurse is assigned to serve as the group facilitator for all inter-professional meetings B. Recognize the knowledge and skills of each team member C. Encourage team members to participate in team meeting and to offer solutions to organizational challenges D. Create an inclusive environment that promotes growth of others E. Use aggressive communication when addressing the team

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

Explanation

Interprofessional collaboration involves shared decision-making and synergistic influence among diverse practitioners. It requires mutual respect to optimize patient outcomes and address complex healthcare delivery systems through integrated clinical expertise and unified goals.

Rationale:

A. Restricting leadership roles to a single profession inhibits the collaborative spirit. Interprofessional teams should rotate the facilitator role to ensure all disciplines have equal representation and influence during clinical coordination meetings.

B. Effective teams must acknowledge expertise inherent in various disciplines. Valuing the unique professional contributions of each member fosters trust and ensures that specific clinical knowledge is utilized for comprehensive patient care plans.

C. Promoting active involvement ensures that diverse perspectives are applied to problem-solving. When staff feel empowered to offer solutions, it improves organizational efficiency and enhances the overall quality of the healthcare environment.

D. Managers must foster a supportive culture that encourages professional development. An inclusive environment minimizes hierarchical barriers, allowing junior and senior staff from different departments to engage in meaningful, non-threatening clinical dialogue.

E. Effective collaboration relies on assertive, not aggressive communication, which creates hostility. Open and respectful dialogue is necessary to prevent medical errors and ensure that information is exchanged accurately among the interprofessional team.

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A nurse is assigned to four clients when arriving for the day shift. Which client should the nurse prioritize for assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prepares to teach a client with hypertension about foods included in a low-sodium diet. Which statements by the client indicate an understanding? Select All That Apply.

Correct Answer is ["A","B","C"]

Explanation

A new nurse manager plans to examine the staff's interprofessional collaboration skills. Which actions by staff should the nurse anticipate to promote interprofessional collaboration? Select All That Apply.

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

Explanation

The clinic nurse is evaluating vital signs for clients being seen in the outpatient clinic. Which client should the nurse see first?

The community health nurse is triaging victims at the disaster site. Which client should the nurse categorize as a black tag?

The charge nurse on the renal unit is notified of a bus accident with multiple injuries, and clients are being brought to the emergency department (ED). The hospital is implementing the disaster policy. Which action should the charge nurse take first?

An unlicensed assistive personnel (UAP) reports to the nurse that a client was found on the floor. Which action should the nurse do after ensuring the client's safety?

The nurse educator is teaching new nurses about whether children may give consent for their own medical treatment. Which statements should the nurse educator use for examples? Select All That Apply.

A community health nurse is researching the social determinants of health across the populations they serve. The nurse should identify which factor places populations at the highest risk for negative health outcomes?

A nurse is delegating collection of a random stool specimen to an unlicensed assistive personnel (UAP). Which information should the nurse provide?

The registered nurse (RN) is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing tasks can the RN delegate or assign? Select All That Apply.