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 D
Explanation
A. Constipation is not typically associated with TPN because the client is receiving nutrients intravenously rather than through the gastrointestinal tract.
B. Respiratory depression is not a direct complication of TPN administration.
C. Hypotension is not a common complication of TPN unless associated with fluid shifts or infection.
D. Electrolyte imbalance is a potential complication of TPN due to the high concentrations of glucose, electrolytes, and other nutrients. Rapid infusion, improper formulation, or abrupt discontinuation can lead to imbalances in sodium, potassium, calcium, magnesium, and phosphate. Frequent monitoring of laboratory values is essential to prevent metabolic complications.
Correct Answer is A
Explanation
A.
A. Hospice care improves quality of life through palliative care - This is a central aspect of hospice care, focusing on pain and symptom management to enhance the patient's comfort and quality of life.
B. Hospice care provides 24-hr, in-home care - While hospice care may provide support, it typically does not offer around-the-clock care in the home.
C. Hospice care is intended to postpone death - Hospice care aims to provide comfort and support in the final stages of life, not to postpone death.
D. Hospice care encourages the family to coordinate health care services - While family
involvement is important, hospice care typically involves a coordinated interdisciplinary team rather than relying solely on family for coordination.
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