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%).

Answer and Explanation

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.

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Correct Answer is B

Explanation

A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.

A. Encourage the client to lie down in a quiet room. B. Avoid eye contact with the client. C. Ask the client directly what he is hearing. D. Refer to the hallucinations as if they are real.

Correct Answer is C

Explanation

A. While rest and a quiet environment can be beneficial, encouraging the client to address the hallucinations directly is more appropriate.
B. Avoiding eye contact may be perceived as dismissive or unhelpful.

C. Engaging the client in open communication about their hallucinations can help build trust and rapport, as well as provide valuable information for treatment planning.
D. Validating hallucinations as real can reinforce delusional thinking and may not be therapeutically beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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