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 D

Explanation

A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.

A. "I have several friends who come by to help out with the baby." B. "I want to meet other parents to see if they are going through the same things." C. "I think the baby should be sleeping through the night by now." D. "I try to respond to the baby quickly so she doesn't cry very long."

Correct Answer is C

Explanation

A. Having social support from friends is a protective factor against child abuse.

B. Seeking support from other parents indicates a healthy coping mechanism and reduces the risk of child abuse.

C. This statement suggests unrealistic expectations about the baby's development and behavior, which could lead to frustration and increased risk of child abuse. Unrealistic expectations are a risk factor for abusive behavior towards children.
D. This statement reflects attentiveness and responsiveness to the baby's needs, which reduces the risk of child abuse.

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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?

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Naxlex Comprehensive Predictor Exams

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