A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

WBC count

Intake and output

ABGs

Blood glucose level

Answer and Explanation

The Correct Answer is C

Rationale:

A. WBC count: Monitoring the white blood cell count is useful for detecting infection, but heroin toxicity primarily affects the respiratory system. An elevated or normal WBC does not provide immediate information about the client's ventilation or gas exchange status.

B. Intake and output: Tracking fluid balance is important for overall patient monitoring, especially in critically ill clients. However, it does not provide direct insight into the effectiveness of mechanical ventilation or the client's oxygenation status.

C. ABGs: Arterial blood gases are the priority assessment because they directly measure the client's oxygenation, ventilation (CO₂ removal), and acid-base status. Since heroin toxicity can cause respiratory depression, ABGs are essential to evaluate the effectiveness of mechanical ventilation.

D. Blood glucose level: Although monitoring glucose is important in critically ill clients, heroin use is not typically associated with hypo- or hyperglycemia. Blood glucose assessment is not as urgent as evaluating respiratory function in this scenario.

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Correct Answer is B

Explanation

Rationale:
A. "If I can keep my HbA1c less than 6.5% (less than 7%), I will be cured of diabetes.": Maintaining an HbA1c below 7% is important for managing type 1 diabetes and reducing complications, but it does not eliminate the disease. Type 1 diabetes is a lifelong condition due to permanent loss of insulin production.

B. "I will check my blood sugar level before exercising.": Blood glucose monitoring before physical activity is essential to prevent hypoglycemia. Exercise lowers blood sugar levels, and clients with type 1 diabetes must assess their levels beforehand to determine if carbohydrate intake or insulin adjustment is needed.

C. "I should have my eyes checked every 2 years.": Clients with type 1 diabetes should have a comprehensive dilated eye exam annually, not every two years, to monitor for diabetic retinopathy, a common microvascular complication.

D. "I should soak my feet daily in warm, soapy water.": Soaking the feet is not recommended because it can lead to skin maceration and increase the risk of infection. Gentle washing and thorough drying—especially between the toes—are safer practices for foot care.

A. The client's bed has a three-prong plug attached to the electrical cord. B. A protective cover is inserted into an unused outlet. C. An IV pump is plugged into an outlet near a sink. D. An electrical cord is coiled and secured to the floor.

Correct Answer is C

Explanation

Rationale:
A. The client's bed has a three-prong plug attached to the electrical cord: A three-prong plug provides grounding and is a standard safety feature. It helps prevent electric shock and is not considered a hazard.

B. A protective cover is inserted into an unused outlet: Outlet covers are recommended, especially in homes with children, to prevent accidental electrical shock. This is a safety measure, not a hazard.

C. An IV pump is plugged into an outlet near a sink: This is a safety hazard because electrical devices should not be used near water sources. The proximity to the sink increases the risk of electrical shock or short-circuiting if moisture contacts the outlet or device.

D. An electrical cord is coiled and secured to the floor: Coiling and securing cords can prevent tripping hazards and is generally acceptable as long as the cord is not damaged or covered in a way that could lead to overheating.

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A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

Nursing Test Bank

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