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 A

Explanation

A. For clients receiving hemodialysis, maintaining adequate protein intake is essential because dialysis can remove protein from the blood. The recommended intake is typically about 1 g/kg/day, which helps replace losses and supports overall health.
B. Consume foods high in potassium. Clients with chronic kidney disease often need to restrict potassium intake due to impaired kidney function and the risk of hyperkalemia.
C. Take magnesium hydroxide for indigestion. Clients with chronic kidney disease should avoid magnesium-containing antacids due to the risk of magnesium accumulation and toxicity.
D. Drink at least 3 L of fluid daily. Fluid intake usually needs to be restricted in clients undergoing hemodialysis because their kidneys cannot effectively remove excess fluid, which can lead to complications like hypertension and pulmonary edema.

A. Position the client in reverse Trendelenburg. B. Assist the client into the lithotomy position. C. Insert a pillow under the client's knees. D. Place a wedge under one of the client's hips.

Correct Answer is D

Explanation

A. Positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration.
B. The lithotomy position is not appropriate for cesarean birth and may compromise blood flow to the placenta.
C. This position could increase pressure on the vena cava and compromise placental blood flow.
D. This lateral tilt relieves pressure on the inferior vena cava, preventing decreased placental blood flow.

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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

A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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