A nurse is planning to prioritize client care after receiving report.
Which of the following clients is a high priority for the nurse to see first?
A client who is short of breath with a pulse oximetry reading of 92
A client who received pain medication 30 minutes ago and reports pain is still a 7/10.
A client who is ambulatory and going for an X-ray at 8:00 AM.
A client scheduled for discharge by 11:00 AM. —
The Correct Answer is A
Choice A rationale
A pulse oximetry reading of 92.
Choice B rationale
A pain level of 7/10 thirty minutes after pain medication is concerning because the medication's onset of action may have been inadequate or the dosage insufficient, necessitating re-assessment and potential breakthrough pain management. While pain management is important, it is not an immediate physiological threat to life or limb like impaired oxygenation is. This is a moderate priority.
Choice C rationale
An ambulatory client scheduled for a diagnostic test is a stable, routine task that can be addressed after higher priority physiological and safety needs are met. This client does not require immediate, life-sustaining intervention. Preparation and transport for the X-ray can be delegated or completed after the critically ill client is stabilized. This is a low priority.
Choice D rationale
Preparing a client for discharge involves administrative tasks, client teaching, and coordination, which are important for continuity of care but are not life-threatening interventions. The 11: AM deadline allows time for this task to be completed after the nurse addresses clients with urgent physiological needs. This is a low priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Furosemide is a potent loop diuretic that causes increased excretion of potassium (K+) in the renal tubules, which can lead to hypokalemia (serum K+ less than 3.5 mEq/L). Increasing the intake of potassium-rich foods, such as spinach and kale, is an essential dietary instruction to help mitigate the risk of this potentially dangerous electrolyte imbalance associated with the medication.
Choice B rationale
Furosemide is prescribed, in part, to manage heart failure and hypertension, conditions that require sodium restriction to reduce fluid retention and circulating blood volume. Encouraging increased sodium intake through foods like luncheon meat and chips would directly counteract the therapeutic goals of the diuretic and exacerbate the client's underlying medical conditions.
Choice C rationale
Diuretics, particularly thiazides and loop diuretics like furosemide, are not typically associated with causing hypoglycemia (low blood sugar). In fact, they can sometimes cause or worsen hyperglycemia (high blood sugar) by impairing insulin release and glucose utilization, making increased intake of sweets an inappropriate and potentially harmful recommendation.
Choice D rationale
While maintaining adequate hydration is important, increasing daily water intake to 3500 mL, especially in a client with heart failure and fluid volume overload, is contraindicated and could worsen the fluid overload. Diuretics are given to remove excess fluid, and fluid intake should be monitored and often restricted to prevent exacerbation of symptoms and further cardiac strain.
Correct Answer is ["2"]
Explanation
Step 1 is: Determine the number of milligrams needed per dose. 650 mg per dose.
Step 2 is: Determine the number of milligrams available per tablet. 325 mg per tablet.
Step 3 is: Calculate the number of tablets to administer. 650 mg ÷ (325 mg/tablet) = 2 tablets. The nurse should administer 2 tablets.
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