A nurse is prioritizing care for four clients. Which client should the nurse assess first?

A client who has a new order for a STAT antibiotic.

A client who is awaiting medication education prior to discharge.

A client who requires a wet-to-dry dressing change.

A client with hypotension and a change in level of consciousness.

Answer and Explanation

The Correct Answer is D

Choice A reason:
A STAT antibiotic indicates urgency, often related to infection; however, administering the medication can usually occur after the nurse addresses immediate life-threatening conditions. This client is stable enough to wait briefly while a more critical client is assessed.

Choice B reason:
Medication education prior to discharge is important for continuity of care and safety after discharge, but it is not an urgent or life-threatening issue. This task can be safely delayed while higher-priority clients are assessed.

Choice C reason:
A wet-to-dry dressing change is a routine wound care intervention. Although it should be completed in a timely manner, it does not take precedence over acute physiologic instability affecting circulation or neurologic status.

Choice D reason:
Hypotension combined with a change in level of consciousness indicates compromised perfusion to vital organs, including the brain. This represents an immediate threat to life and requires rapid assessment and intervention following airway, breathing, and circulation priorities.

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Correct Answer is C

Explanation

Choice A reason:
Dextrose 2.5% in water is a hypotonic solution once the dextrose is metabolized. Hypotonic fluids cause water to shift into cells, which can lead to cellular swelling. This fluid is not isotonic and is therefore incorrect.

Choice B reason:
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution. It provides free water and promotes fluid movement into cells, making it inappropriate to classify as isotonic.

Choice C reason:
0.9% sodium chloride, also called normal saline, has an osmolality similar to that of plasma. It does not cause significant fluid shifts between compartments and is classified as an isotonic solution. It is commonly used for fluid resuscitation and maintenance of intravascular volume.

Choice D reason:
Dextrose 10% in water is a hypertonic solution. It draws water out of cells into the intravascular space and increases serum osmolality. Because of this effect, it is not isotonic and is an incorrect choice.

A. Pale yellow urine B. Oral temperature of 99 F (37.2 C) C. Moist mucous membranes D. Blood pressure 90/49 mmHg

Correct Answer is D

Explanation

Choice A reason:
Pale yellow urine is generally within normal limits and indicates adequate hydration. This finding does not suggest a complication requiring immediate action.

Choice B reason:
An oral temperature of 99 F (37.2 C) is considered a low-grade or normal temperature. It does not indicate infection or dehydration that would require urgent intervention.

Choice C reason:
Moist mucous membranes suggest that the client’s hydration status is currently adequate. This assessment does not raise immediate concern despite ongoing nausea and vomiting.

Choice D reason:
A blood pressure of 90/49 mmHg indicates hypotension, which may result from fluid loss due to persistent vomiting. Hypotension is a sign of potential hypovolemic shock or severe dehydration, requiring prompt nursing assessment and intervention to prevent complications such as organ hypoperfusion or syncope.

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A nurse is prioritizing care for four clients. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intravenous fluid is classified as an isotonic solution?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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