Try Naxlex NCLEX-RN (Free-Trial)

A nurse is receiving bedside shift report on four assigned patients. Using clinical judgment and priority-setting principles, which patient requires the nurse to assess first?

A 55-year-old patient with an acute kidney injury (AKI) whose morning potassium level is 5.1 (normal 3.5-5.0) and who is waiting for the stat dose of sodium polystyrene sulfonate (Kayexalate) to be delivered from the pharmacy.

A 72-year-old patient 4 hours post-percutaneous coronary intervention (PCI) with a non-bleeding groin puncture site and a reported dull, constant backache rated 4/10.

A 45-year-old patient with a history of seizures who missed the 0600 dose of phenytoin (Dilantin) because it was held for a critically low albumin level.

A 60-year-old patient with chronic obstructive pulmonary disease (COPD) and a tracheostomy whose heart rate is 105/min (baseline 88/min) and whose family member reports a sudden increase in noisy respirations.

Answer and Explanation

The Correct Answer is D

Priority-setting in acute care follows the ABCs framework (airway, breathing, circulation) and focuses on immediate threats to oxygenation and ventilation. Patients with respiratory compromise, especially those with COPD and artificial airways, are at high risk for rapid deterioration due to airway obstruction, secretion retention, and impaired gas exchange.

Rationale:

A. 5.1 mmol/L is only mildly elevated and does not indicate immediate life-threatening hyperkalemia. The patient is stable while awaiting sodium polystyrene sulfonate. No ECG changes or severe electrolyte imbalance are described, so this is not the first priority.

B. Post-PCI patients require monitoring for complications such as bleeding or retroperitoneal hemorrhage. However, a stable groin site and mild backache rated 4/10 suggest no immediate hemodynamic instability. This finding warrants assessment but is not the highest priority.

C. Missed phenytoin dose due to low albumin is important but not immediately life-threatening. While seizure risk may increase, there is no active seizure or neurologic deterioration described. This represents a medication management issue rather than an acute emergency.

D. A COPD patient with a tracheostomy and sudden increase in noisy respirations indicates possible airway obstruction from mucus plugging or secretion buildup. The elevated heart rate suggests early respiratory distress and hypoxemia. This is an immediate airway emergency requiring urgent assessment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Open-angle glaucoma involves progressive optic nerve damage from increased intraocular pressure, leading to peripheral vision loss. It is typically asymptomatic early, with gradual visual field constriction. Untreated progression results in irreversible blindness due to retinal ganglion cell loss.

Rationale:

A. Impaired central vision is not an early feature of open-angle glaucoma and occurs later in advanced disease. Early changes affect peripheral fields first. Absence of central involvement and presence of early field loss make this incorrect.

B. Impaired peripheral vision is the hallmark early sign of open-angle glaucoma due to optic nerve fiber damage. Patients develop tunnel vision over time. Presence of visual field loss and progressive peripheral deficit directly supports this diagnosis.

C. Eye pain is typically absent in open-angle glaucoma and is more characteristic of acute angle-closure glaucoma. This condition progresses silently. Lack of ocular pain and gradual asymptomatic course make this finding inconsistent.

D. Opacity of the lens indicates cataract formation, not glaucoma. Cataracts cause clouded vision rather than increased intraocular pressure. Presence of lens opacity without optic nerve damage differentiates it from glaucoma.

A. Bell's Palsy B. Goiter C. Graves disease D. Mumps E. Pancreatitis

Correct Answer is D

Explanation

Paramyxovirus infection causes parotitis with painful glandular swelling, fever, and malaise. Viral replication in salivary epithelium leads to inflammation, edema, and ductal obstruction. Complications include orchitis, meningitis, and pancreatitis. Transmission occurs via respiratory droplets.

Rationale:

A. Bell’s palsy is an acute peripheral facial nerve paralysis affecting cranial nerve VII, leading to unilateral facial weakness. It does not involve salivary gland enlargement. Absence of parotid swelling and presence of facial paralysis distinguish it from infectious parotitis.

B. Goiter refers to enlargement of the thyroid gland, typically presenting as anterior neck swelling. It is associated with iodine imbalance or thyroid dysfunction. The thyroid location differs anatomically from the parotid glands, and neck mass presentation excludes salivary gland involvement.

C. Graves disease is an autoimmune hyperthyroid condition characterized by diffuse thyroid enlargement, ophthalmopathy, and hypermetabolic symptoms. It does not cause parotid gland swelling. The presence of thyrotoxicosis and exophthalmos differentiates it from viral parotitis.

D. Mumps is a viral infection causing bilateral painful swelling of the parotid glands due to inflammation and edema. It commonly presents with fever and malaise. The hallmark bilateral swelling and parotitis directly indicate this condition.

E. Pancreatitis involves inflammation of the pancreas, presenting with epigastric pain and elevated pancreatic enzymes. Although mumps can cause pancreatitis as a complication, it does not cause parotid enlargement independently. Abdominal pain and enzyme elevation are primary findings.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is receiving bedside shift report on four assigned patients. Using clinical judgment and priority-setting principles, which patient requires the nurse to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is treating a patient diagnosed with the beginning stages of open-angle glaucoma. Which assessment data support this diagnosis?

Correct Answer is B

Explanation

The nurse notes bilateral enlargement of the parotid glands. Which condition does the nurse suspect?

Correct Answer is D

Explanation

Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

The patient is standing 10 feet from the eye chart but can only read what a person with normal vision could see from 200 feet away. What does the nurse document about the patient's vision?

A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. Based on the patient's presentation, which of the following hormones is the patient most likely deficient in? Select all that apply.

Which statements are true about the lymph nodes of the head, face, & neck? Select all that apply.

A patient complains of tinnitus. Which question should the nurse ask next?

The nurse is teaching a group of women about health-promoting interventions. Which health interventions are most responsible for the decline in cervical cancer rates? Select all that apply.

Which recommendations should the nurse give to treat epistaxis? Select all that apply.

A nurse is performing a head assessment on a newborn. Which finding should the nurse report to the provider immediately?