A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has sinus arrhythmia and is receiving cardiac monitoring.
A client who has a hip fracture and a new onset of tachypnea.
A client who has epidural analgesia and weakness in the lower extremities.
A client who has diabetes mellitus and an HbA1c of 7.2% (less than 7%).
The Correct Answer is B
A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using rubbing alcohol to remove ink markings is not recommended as it can irritate the skin, especially in areas undergoing radiation therapy.
B. Altered taste sensations are a common side effect of radiation therapy, especially when the therapy is targeted near the head or neck. The nurse should inform the client about potential changes in taste perception and provide strategies to cope with them.
C. Wearing a binder over the radiation site is unnecessary and may cause discomfort or interfere with treatment.
D. Washing the skin thoroughly with a washcloth after each treatment is not necessary; gentle cleansing with mild soap and water is sufficient.
Correct Answer is C
Explanation
A. Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a risk factor for congenital birth defects.
B. Antibiotics are not effective against viral infections and should not be used unnecessarily.
C. Waiting until the chickenpox sores have crusted reduces the risk of transmission, indicating an understanding of infection prevention. This statement reflects appropriate knowledge about infectious disease control during pregnancy.
D. While handwashing is important, the recommended duration is at least 20 seconds, and hot water is not necessary for effective hand hygiene.
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