A nurse is caring for four clients.
Which one would the nurse see first?

A client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.

A client who had a first dose of captopril and needs to use the bathroom.

A hypertensive client with a blood pressure of 188/92 mm Hg.

A client who needs pain medication prior to a dressing change of a surgical wound.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A blood pressure of 98/58 mm Hg in a client who needs a beta blocker is a significant safety concern. Beta blockers work by blocking the effects of epinephrine, which can cause a decrease in heart rate and blood pressure. Administering a beta blocker to a client with a pre-existing low blood pressure (normotensive range is 120/80 mm Hg) could cause a profound and dangerous drop in blood pressure, leading to hypotension, syncope, and inadequate organ perfusion. This client needs immediate assessment before medication administration.

Choice B rationale

A client needing to use the bathroom after taking captopril is not an immediate priority. While captopril can cause hypotension, the primary concern is the potential for a first-dose hypotensive effect. However, a client's need to void is a common and expected request and does not indicate an acute, life-threatening crisis requiring immediate intervention before other clients.

Choice C rationale

A blood pressure of 188/92 mm Hg, while elevated, is not an immediate life-threatening emergency unless there are signs of end-organ damage (e.g., chest pain, neurological changes). This is considered a hypertensive urgency, which requires a prompt but not immediate intervention to lower the blood pressure gradually. This client is stable and can be assessed after the client in Choice A, who is at risk for a profound hypotensive event.

Choice D rationale

A client needing pain medication before a dressing change is not the highest priority. Pain management is an important aspect of care, but it is not an acute physiological emergency. Delaying pain medication for a short time to address a life-threatening physiological instability in another client is an appropriate triage decision. The client in Choice A is at higher risk for a critical physiological event. .

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Correct Answer is A

Explanation

Choice A rationale

Wool fibers have a rough, coarse texture that can mechanically irritate the delicate skin of an infant with eczema. This physical abrasion can trigger an inflammatory response and exacerbate the itching and rash associated with the condition. The goal is to use smooth, breathable fabrics like cotton to minimize skin friction.

Choice B rationale

Fragrances and dyes in laundry detergents are common chemical irritants and allergens that can cause contact dermatitis and worsen eczema symptoms. Avoiding these additives is crucial for minimizing exposure to potential triggers and reducing inflammation and itching in sensitive skin.

Choice C rationale

Putting cotton gloves or socks on an infant's hands is a practical strategy to prevent the infant from scratching their skin. The mechanical trauma from scratching can break the skin barrier, leading to secondary infections and worsening the eczema flare-up.

Choice D rationale

Keeping fingernails short is a fundamental measure to prevent the skin damage caused by scratching. Long, sharp nails can tear the skin, creating entry points for bacteria and increasing the risk of infection, a common complication of poorly controlled eczema.

A. Cover the hair with Vaseline. B. Apply a soda-vinegar solution to the hair. C. Comb through the hair with a vinegar-water solution. D. Shampoo the hair with dish detergent.

Correct Answer is C

Explanation

Choice A rationale

While occlusive agents like Vaseline can smother lice, this method is messy and generally not as effective as targeted pediculicides. It mainly suffocates the live lice but does not consistently eliminate the nits (eggs), which are tightly attached to the hair shaft and must be removed to prevent reinfestation.

Choice B rationale

A soda-vinegar solution has no proven efficacy in eradicating lice. The acetic acid in vinegar can help loosen the glue-like substance that attaches nits to the hair shaft, but it is not a standalone treatment. Baking soda does not have any scientific basis for being effective against pediculosis.

Choice C rationale

A vinegar-water solution, specifically the acetic acid in vinegar, helps to dissolve the proteinaceous cement substance that glues nits to the hair shaft. This makes the nits easier to remove with a fine-toothed nit comb, which is a crucial step in the eradication process to prevent the hatching of new lice.

Choice D rationale

Dish detergents are not formulated to be effective against lice and can be harsh on the scalp, causing irritation. They lack the specific neurotoxic agents or suffocation properties found in approved pediculicide shampoos that are designed to kill lice and their eggs. This method is ineffective and potentially harmful. .

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A nurse is caring for four clients. Which one would the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement made by a parent indicates the need for further teaching about strategies to control itching for the infant with eczema?

Correct Answer is A

Explanation

The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice?

Correct Answer is C

Explanation

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports a new-onset cough. What action by the nurse is most appropriate?

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake.What answer by the nurse is best?

After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching?

A group of football players is taking oral griseofulvin for tinea pedis. What should the school nurse caution them to avoid?

A nurse is preparing a teaching plan for the care of a child with infantile eczema. What interventions would the nurse include? (Select all that apply.)

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What query asked next by the nurse will give the best information?

The recommended dosage of amoxicillin is 20 to 40 mg/kg/day divided in equal doses q h. The medication is supplied as a 50 mg/mL oral suspension. The child weighs 72.6 lb. How many milliliters will be administered for a single dose if the child is receiving the 20 mg/kg/day dosage?

A nurse is caring for four clients.
Which one would the nurse see first?