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 a hip fracture and a new onset of tachypnea.
A client who has diabetes mellitus and an HbA1c of 6.8%.
A client who has epidural analgesia and weakness in the lower extremities.
A client who has sinus arrhythmia and is receiving cardiac monitoring.
The Correct Answer is A
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism. The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is well- controlled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A.
Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Inserting the catheter without applying suction is correct technique. Suction should only be applied while withdrawing the catheter to prevent mucosal trauma and hypoxia. Initiating suction during insertion can damage tracheal lining and cause bradycardia due to vagal stimulation. Allowing clean insertion without suction reduces injury risk and supports effective secretion removal on withdrawal with controlled suction time.
Choice B rationale: Waiting 2 minutes between suction passes is too long and may delay secretion clearance, risking hypoxia and secretion buildup. Best practice is to wait about 30 seconds to 1 minute or until the client recovers baseline oxygen saturation and heart rate. Prolonged intervals may lead to atelectasis or respiratory distress in patients with poor reserve, especially if suctioning is incomplete or secretions are copious.
Choice C rationale: Suctioning should be limited to 10–15 seconds per pass to reduce hypoxemia and bronchospasm risks. Applying suction for 15 seconds falls within the upper acceptable range, particularly if preoxygenation is done. Extended suction beyond this can decrease PaO₂ levels rapidly. Limiting the suction time ensures safer removal of secretions while minimizing trauma and preserving adequate oxygenation.
Choice D rationale: Encouraging the client to cough facilitates mobilization of secretions toward the upper airway, making suctioning more effective. Coughing also enhances airway clearance naturally and may reduce the number of required suction passes. It is a therapeutic action in tracheostomy care that supports pulmonary hygiene, helps prevent atelectasis, and can reduce the need for deep suctioning interventions.
Correct Answer is ["C","E"]
Explanation
A urine culture is indicated for the client who has lower back pain and pinkish vaginal discharge, as these symptoms may suggest a urinary tract infection (UTI). A urine culture can identify the causative organism and guide the appropriate antibiotic therapy.
Phenazopyridine is a urinary analgesic that can relieve pain, burning, and urgency associated with a UTI. However, it requires a provider prescription and should not be used for more than two days.
A vaginal culture is not necessary for this client, as the vaginal discharge is likely due to the cervical changes during labor. A vaginal culture may be indicated for clients who have signs of vaginitis, such as itching, odor, or abnormal color of the discharge.
Obtaining a provider prescription for antibiotics is premature for this client, as the urine culture results are not available yet. Antibiotics should be prescribed based on the sensitivity of the organism causing the UTI.
Ibuprofen 600 mg every 6 hr for mild to moderate pain is not appropriate for this client, as it may interfere with uterine contractions and prolong labor. Ibuprofen is also contraindicated in the third trimester of pregnancy due to the risk of premature closure of the ductus arteriosus in the fetus. The nurse should use nonpharmacological methods to relieve the client’s back pain, such as massage, heat, or position changes.
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