A nurse is planning care after receiving reports for four clients. Which of the following clients should the nurse plan to assess first?

A client who has a BP of 118/74 mm Hg and is receiving treatment for hypertension

A client who has diabetes mellitus and a fasting blood glucose of 118 mg/dl (70 to 110 mg/dl)

A client who is 2 days postoperative and has a urinary output of 500 mL/24 hr

A client who has a heart rate of 68/min and is receiving IV fluids

Answer and Explanation

The Correct Answer is C

Rationale:

A. This option is incorrect because a blood pressure of 118/74 mm Hg falls within normal limits, even for a client being treated for hypertension. While monitoring is important, there is no immediate threat to the client’s safety that would require urgent assessment.

B. This option is incorrect because a fasting blood glucose of 118 mg/dL is slightly above the normal range (70–110 mg/dL) but does not pose an immediate risk for harm. This client’s condition can be monitored and addressed after higher-priority concerns are evaluated.

C. This option is correct because a urinary output of 500 mL over 24 hours is considered oliguria, which is significantly below the expected output of approximately 0.5–1 mL/kg/hr for adults. In a postoperative client, oliguria can indicate acute kidney injury, hypovolemia, or obstruction and may lead to serious complications if not addressed promptly. Early assessment is crucial to determine the cause and implement interventions such as fluid management, monitoring electrolytes, or notifying the provider. This makes the client the highest priority for assessment.

D. This option is incorrect because a heart rate of 68/min is within normal limits for an adult. While ongoing monitoring of IV fluids and vital signs is necessary, there is no immediate indication of instability that would require urgent attention.

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Correct Answer is D

Explanation

Rationale:

A. This option is incorrect because an assisted living facility provides long-term housing with support for activities of daily living, but it is not designed to offer short-term relief for a caregiver managing a terminally ill client at home.

B. This option is incorrect because social services can provide guidance on resources and financial assistance, but they do not provide direct, temporary care for the client while the primary caregiver attends to personal needs.

C. This option is incorrect because a spiritual support person can provide emotional and spiritual guidance but does not offer physical care or supervision for the client.

D. This option is correct because respite care provides temporary relief for primary caregivers by offering short-term, supervised care for the client. This allows the caregiver to attend personal errands, rest, or manage other responsibilities while ensuring the client continues to receive safe, quality care at home. Respite care is especially important for caregivers managing clients with advanced illnesses.

A. "They cannot be changed once I have signed it." B. "They will need to be reviewed by my attorney." C. "They will require me to appoint a durable power of attorney." D. "They will include my preferences for end-of-life treatment."

Correct Answer is D

Explanation

Rationale:

A. This option is incorrect because advance directives are not permanent and can be changed or revoked at any time, as long as the client is competent to make healthcare decisions. Clients may revise their directives to reflect changes in their health status, personal values, or preferences for medical care. Telling clients they cannot be changed could lead to misunderstandings about their rights and autonomy.

B. This option is incorrect because while consulting an attorney may provide legal guidance, it is not a required step for creating an advance directive. Many advance directives are valid when completed using standardized forms provided by healthcare facilities or state resources without legal review.

C. This option is incorrect because appointing a durable power of attorney (also called a healthcare proxy) is optional. While designating someone to make healthcare decisions on the client’s behalf can be helpful, especially if the client becomes incapacitated, it is not mandatory for an advance directive to be valid.

D. This option is correct because advance directives are intended to document a client’s preferences for end-of-life care. This includes decisions about life-sustaining treatments, resuscitation (CPR), mechanical ventilation, feeding tubes, and other medical interventions. By having an advance directive, clients ensure that their wishes are respected if they become unable to communicate or make healthcare decisions in the future. This empowers clients, guides healthcare providers, and helps prevent unwanted or unnecessary interventions.

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Ethical principle	Findings
Autonomy	Informed consent obtained by provider and verified by nurse. Provider prescriptions for a mammogram and ultrasound of the breasts. Client reassured that medical records remain confidential.
Fidelity	Client reassured that staff will treat all clients equally. Client provided with additional information about recovery as promised at last visit. Client states, "I have a bad feeling about this, tell me the truth even if it's bad news."
Nonmaleficence	Documentation of living will and durable power of attorney on client's chart. Evidence-based standards of postoperative care reviewed with nursing staff prior to procedure. Client provided resources for support groups for clients who have diagnosis of cancer.

A nurse is planning care after receiving reports for four clients. Which of the following clients should the nurse plan to assess first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is teaching a client about the purpose of advance directives. When assessing the client's understanding of the teaching, which of the following client statements should the nurse expect?

Correct Answer is D

Explanation

A nurse is planning care for a client who has hemiparesis and dysphagia following a stroke. The nurse should collaborate with which of the following members of the interprofessional team to assist the client with managing ADLs? (Select all that apply.)

A nurse is providing discharge teaching to a client's adult child regarding the client's discharge to home with hospice care. Which of the following statements by the client's adult child indicates an understanding of the teaching?

A nurse is prioritizing care for four clients. Which of the following clients should be the nurse's priority?

A nurse is admitting a client who has heart failure and speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client using an interpreter?

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