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: Tachycardia might occur due to the fever itself but isn't a specific reaction to the cooling method.
B: Shivering is an adverse reaction because it indicates that the body is trying to generate heat to counteract the cooling effect of the blanket, which can increase metabolic demand and is counterproductive.
C: Flushing is typically related to fever or other causes but not directly to the adverse reaction of cooling.
D: Restlessness can be caused by discomfort or the fever itself, not specifically by cooling.
Correct Answer is C
Explanation
A. While metronidazole is an antimicrobial medication, it does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
B. Ampicillin sodium is an antibiotic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
C. Doxorubicin hydrochloride is a cytotoxic chemotherapy medication that poses a significant biohazard risk due to its potential carcinogenic and mutagenic properties. Specific facility procedures for handling cytotoxic spills should be followed.
D. Phenytoin is an antiepileptic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
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