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 D
Explanation
a. Clients with compromised immunity are often placed in protective environments, but not necessarily in negative air pressure rooms. These rooms are typically reserved for clients on airborne precautions.
b. An N95 respirator is required for airborne precautions, not droplet precautions. A regular surgical mask is sufficient for droplet precautions.
c. Contact precautions primarily focus on preventing the transmission of pathogens through direct or indirect contact. Visitors are usually instructed to wear personal protective equipment (PPE) when entering the room, but the focus is on healthcare workers wearing PPE during patient care.
d. A client on airborne precautions (e.g., for tuberculosis or measles) should wear a mask (preferably an N95 or equivalent) when leaving the room to prevent spreading airborne pathogens
Correct Answer is C
Explanation
a. While educating the client about the risks of refusing the procedure is important, it should not be the first action taken when the client does not understand the procedure itself.
b. Completing an incident report is not necessary in this situation, as there is no indication of an adverse event or error.
c. When a client does not understand a procedure, it is essential to inform the provider so that they can provide clarification and address any questions or concerns the client may have.
d. While answering the client's questions is important, the nurse may not have the expertise or authority to provide the level of clarification required. It is best to involve the provider in this situation.
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