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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E"]

Explanation

The nurse should include the following statements in the teaching:

You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.

Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.

A. “The more my baby is at the breast sucking, the more milk I will produce.” B. “Manually expressing my milk will decrease my milk supply.” C. “After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.” D. “My baby should always start on the same breast when feeding.” E. “My baby should always start on the same breast when feeding.”

Correct Answer is A

Explanation

This statement indicates an understanding of the teaching because it reflects the principle of supply and demand in breastfeeding. The more the baby stimulates the breast, the more milk the mother will produce.

Choice B is wrong because manually expressing milk will not decrease the milk supply. In fact, it can help increase the milk supply by removing more milk from the breast and signaling the body to make more.

Choice C is wrong because the breast is not emptied after 5 to 10 minutes of feeding. The baby should be allowed to nurse until they are satisfied and show signs of fullness, such as releasing the nipple, falling asleep, or turning away from the breast. The average duration of a feeding session can vary from 10 to 45 minutes.

Choice D is wrong because the baby should not always start on the same breast when feeding. The mother should alternate which breast she offers first to ensure both breasts are stimulated and drained equally.

This can help prevent engorgement, mastitis, and low milk supply. A simple way to remember which breast to start with is to wear a bracelet or a clip on the bra strap on the side that needs to be offered next.

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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

A nurse in an emergency department is caring for a client Exhibits The nurse is providing teaching to the client about self-care. Select the 3 statements the nurse should include in the teaching.

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

Explanation

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