A nurse is receiving change-of-shift report about the care of four clients. Which of the following clients should the nurse see first?

A client who has a blood pressure of 138/88 mm Hg

A client who reports a pain level of 4 on a scale of 0 to 10

A client who has a blood glucose level of 128 mg/dL (74 to 106 mg/dL)

A client who displays increased confusion over the past 4 hr

Answer and Explanation

The Correct Answer is D

A. A client who has a blood pressure of 138/88 mm Hg: This blood pressure is only slightly elevated and does not indicate immediate instability. The client is not at acute risk of deterioration, so this finding does not require priority assessment over neurologic changes.

B. A client who reports a pain level of 4 on a scale of 0 to 10: Moderate pain needs attention but does not suggest life-threatening compromise. This level of pain allows time for assessment and intervention without posing immediate danger compared to acute cognitive changes.

C. A client who has a blood glucose level of 128 mg/dL (74 to 106 mg/dL): A glucose of 128 mg/dL is mildly elevated and not emergent. It does not place the client at risk for imminent complications and can be addressed after more urgent concerns.

D. A client who displays increased confusion over the past 4 hr: Sudden or worsening confusion can indicate acute neurologic issues such as hypoxia, infection, stroke, or metabolic imbalance. Changes in level of consciousness are high-priority findings due to the potential for rapid deterioration, making this client the first to assess.

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Correct Answer is ["C","D","E"]

Explanation

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors is unnecessary and may increase feelings of isolation. Social support from friends and peers can enhance emotional adjustment and motivation during rehabilitation.

B. Instruct the client to ignore phantom pain sensations: Ignoring phantom limb pain is not effective; the client should be taught coping strategies, pain management techniques, and report persistent pain to the healthcare team for appropriate interventions.

C. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support provides encouragement, realistic expectations, and shared coping strategies. This intervention can enhance the client’s adjustment and promote psychological well-being.

D. Ask the client to describe her feelings about the loss of the affected limb: Encouraging the client to express emotions supports grief processing and emotional adjustment. Open communication helps the nurse assess psychological needs and provide targeted support.

E. Suggest that family members bring clothing for the client from home: Familiar clothing can increase comfort, provide a sense of normalcy, and support the client’s dignity and autonomy during rehabilitation. Personal items contribute to a supportive healing environment.

A. Instruct the client to tilt their head back to facilitate swallowing. B. Schedule physical therapy directly before meals. C. Provide oral care before meals. D. Encourage the client to use a straw.

Correct Answer is C

Explanation

A. Instruct the client to tilt their head back to facilitate swallowing: Tilting the head back increases the risk of aspiration in clients with dysphagia. Proper swallowing technique usually involves a slight forward or chin-tuck position to protect the airway during eating.

B. Schedule physical therapy directly before meals: Physical therapy immediately before meals may cause fatigue, increasing the risk of choking or aspiration during feeding. Mealtimes should be planned when the client is alert and rested to ensure safe swallowing.

C. Provide oral care before meals: Performing oral care before meals removes bacteria and food debris, reducing the risk of aspiration pneumonia. A clean mouth also improves taste sensation and stimulates saliva, aiding the swallowing process safely.

D. Encourage the client to use a straw: Using a straw can increase the risk of choking or aspiration for clients with dysphagia because it can deliver liquid too quickly and bypass natural swallowing coordination. Direct sipping from a cup under supervision is safer.

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A nurse is receiving change-of-shift report about the care of four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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