A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?
A client who has gastroenteritis and is lethargic and confused
A client who has cystic fibrosis, has a thick, productive cough, and reports thirst
A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic
A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL
The Correct Answer is A
A.
A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.
B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.
C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.
D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Herpes simplex virus (HSV) type 1 infection is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
B. Hepatitis A is a reportable infectious disease to the CDC due to its potential for public health significance, particularly in outbreaks or clusters of cases.
C. Human papillomavirus (HPV) infection is not typically a reportable diagnosis to the CDC unless it is part of a larger study or surveillance effort.
D. Pediculosis capitis (head lice infestation) is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
Correct Answer is D
Explanation
A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.
B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.
C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.
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