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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.
Correct Answer is B
Explanation
a. Administering a sedative should not be the first response, as it may not address the underlying cause of the behavior and may increase the risk of adverse effects.
b. Contacting a family member to provide support and comfort to the client can help alleviate agitation and may help redirect the client's behavior.
c. Placing the client in a wheelchair with a lap tray does not address the underlying cause of the behavior and may not be effective in managing agitation.
d. Keeping the client in her room with the door closed may isolate the client but does not address the underlying cause of the behavior or provide appropriate support.
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