A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A client who is 3 days postoperative following abdominal surgery is ready for discharge
A client who has Alzheimer's disease and bacterial pneumonia with newly onset restlessness
A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7
A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
The Correct Answer is B
A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reporting infections like chlamydia to the local health department is crucial for public health monitoring and contact tracing to prevent further spread of the infection.
B. Chlamydia is a bacterial infection, and antiviral creams are not effective against it.
C. While advising the client about preventive measures like condom use is important, reporting the infection is the priority for public health purposes.
D. Contact precautions are not necessary for chlamydia as it is primarily spread through sexual contact and not through casual contact or airborne transmission.
Correct Answer is D
Explanation
A. Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B. Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C. Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D. Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.
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