A nurse is caring for four clients. Which of the following clients should the nurse assess first?

A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness

A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10

A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Answer and Explanation

The Correct Answer is A

a.   The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b.   While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c.   Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d.   The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.

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Correct Answer is A

Explanation

a. Transcutaneous electrical nerve stimulation (TENS) is a form of physical therapy often used for pain management. Therefore, the physical therapist would be the appropriate member of the interdisciplinary team to contact for assistance with TENS.
b. Respiratory therapists primarily focus on respiratory care and would not typically be involved in assisting with TENS therapy.
c. Occupational therapists focus on helping clients perform activities of daily living and may not have specific expertise in managing TENS therapy.
d. While pharmacists are knowledgeable about medications, they may not have the expertise required to assist with TENS therapy, which is a form of physical therapy.

A. The time the client received his last dose of pain medication B. The belief that the client has a difficult relationship with his son C. The steps to follow when providing wound care D. The client's preferred time for bathing

Correct Answer is A

Explanation

- A) Knowing the time the client received his last dose of pain medication is crucial for continuity of care, ensuring that the client receives their next dose on time and pain management is consistent.
- B) Personal beliefs about the client's relationships are not relevant to the medical care and should remain confidential unless it directly impacts the care plan.
- C) While important, the detailed steps for wound care will be included in the client's care plan and are not typically communicated during a change-of-shift report unless there is a change or an issue.
- D) The client's preferred time for bathing is a part of personal care preferences and, while important for client comfort, is not critical information for a change-of-shift report unless it affects immediate care needs.

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A nurse is caring for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance?

Correct Answer is A

Explanation

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

A nurse is preparing a teaching session with a client who speaks a different language than the nurse. Which of the following interventions should the nurse plan to include?

26) a nurse is preparing to complete an incident report regarding a medication error which of the following actions should the nurse plan to take? select all that apply

A nurse is working on a medical-surgical unit and is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is the appropriate procedure for taking care of the client's ring?

A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

A nurse is teaching a newly licensed nurse about client confidentiality. The nurse should include which of the following examples represents a violation of client confidentiality?