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 A

Explanation

A. "I will hold pressure to the site after the procedure.": Firm pressure is required after a bone marrow aspiration to reduce bleeding because the needle penetrates highly vascular bone tissue. Applying pressure also helps prevent hematoma formation at the puncture site.

B. "You will need to fast for 2 hours before the procedure.": Fasting is not required because the procedure is performed using local anesthesia and does not involve sedation in most cases. Clients can eat normally without affecting the accuracy or safety of the aspiration.

C. "You will not receive a local anesthetic agent for this procedure.": A local anesthetic is routinely administered to numb the skin and periosteum to reduce discomfort during needle insertion. Although pressure or brief sharp pain may still occur, anesthesia is an essential part of the procedure.

D. "You will have the bone marrow taken from your femur.": The posterior iliac crest is the preferred site in adults because it provides easy access and yields adequate marrow safely. The femur is rarely used except in certain pediatric situations or special circumstances.

A. Limit instructions to two steps at a time. B. Vary the staff providing care for the client. C. Encourage socialization as a distractor when the client becomes agitated. D. Encourage independence in ADLS.

Correct Answer is A

Explanation

A. Limit instructions to two steps at a time: Clients with Alzheimer's disease have impaired short-term memory and difficulty processing complex information. Providing simple, stepwise instructions improves comprehension and reduces frustration during care activities.

B. Vary the staff providing care for the client: Frequent changes in caregivers can increase confusion and anxiety in clients with Alzheimer's disease. Consistent staffing promotes a sense of familiarity, security, and trust, which supports overall well-being.

C. Encourage socialization as a distractor when the client becomes agitated: While social interaction can be beneficial, forcing socialization during agitation may worsen confusion or stress. Interventions should focus on calming strategies and meeting the client’s immediate needs.

D. Encourage independence in ADLS: Promoting independence is important but must be balanced with the client’s cognitive and functional abilities. Overemphasis on independence without support may lead to frustration or safety risks during daily activities.

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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 is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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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?