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

Answer and Explanation

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.

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Correct Answer is C

Explanation

a. Assault:

Assault involves the threat of bodily harm or unwanted physical contact that creates fear or apprehension in the victim. In this scenario, there is no indication of a threat being made against the client; instead, the nurse administers the medication without their consent.

b. Libel:

Libel refers to a false written statement that damages a person's reputation. This option is not applicable to the scenario described, as it does not involve written communication or defamation of character.

c. Battery:

Battery occurs when there is unauthorized physical contact with another person that results in harm or offense. In this scenario, the nurse administers the injection against the client's will, which constitutes unauthorized physical contact, making it an example of battery.

d. False imprisonment:

False imprisonment involves unlawfully restraining or confining a person against their will. While administering medication without consent could potentially be perceived as a form of restraint, false imprisonment typically involves physical confinement or restriction of movement, which is not the case in this scenario.

A. A client who has just returned from the PACU B. A client who has a blood pressure of 110/68 mm Hg C. A client who is experiencing chest pain D. A client who has a fasting blood glucose of 104 mg/dL

Correct Answer is B

Explanation

a. A client who has just returned from the PACU:

Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.

b. A client who has a blood pressure of 110/68 mm Hg:

This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.

c. A client who is experiencing chest pain:

Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.

d. A client who has a fasting blood glucose of 104 mg/dL:

Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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