A nurse is caring for four clients. Which of the following 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 to 10
A client who is 3 days postoperative following abdominal surgery and is ready for discharge
The Correct Answer is A
a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.
b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.
c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.
d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. "I will ask your mother's primary care provider to speak with you."This response does not address the issue of confidentiality and consent. The nurse should not assume that the provider will discuss the treatment without the client's consent.
B.“You will have to speak directly to your mother about her treatment.”This response correctly redirects the child to the client but does not fully explain the importance of consent and confidentiality, which are crucial in maintaining professional and ethical standards.
C.“What would you like to know about your mother’s treatment.”This response might imply a willingness to share information without the client’s consent, which would be a violation of confidentiality and privacy laws.
D.“I cannot provide this information to you without your mother’s consent.”Correct. This response clearly states the need for the client’s consent before any information can be shared, adhering to the principles of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) regulations.
Correct Answer is A
Explanation
a. Prepare to administer antibiotics to the client.
This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.
b. Wear an N95 respirator mask while caring for the client.
While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.
c. Plan to administer an antiviral medication to the client.
Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.
d. Place a surgical mask on the client during transfer to the unit.
Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.