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.
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Related Questions
Correct Answer is C
Explanation
Valsartan is a medication that lowers blood pressure by blocking the action of angiotensin II, a hormone that causes blood vessels to constrict. By dilating the blood vessels, valsartan reduces the pressure in the arteries and improves blood flow to the organs. However, if the dose of valsartan is too high, it can cause excessive lowering of blood pressure, which can lead to symptoms such as dizziness, fainting, blurred vision, or nausea. This is especially likely when the client changes position from lying or sitting to standing, which is called orthostatic hypotension. Therefore, the nurse should monitor the client’s blood pressure and pulse in different positions and report any significant changes to the provider. The nurse should also instruct the client to rise slowly from a lying or sitting position and to avoid driving or operating machinery until the effects of the medication wear off.
Choice A is wrong because monitoring the client’s urine output is not a priority action for a client who received an overdose of valsartan.
Valsartan does not have a direct effect on urine output, although it may affect kidney function in some cases. The nurse should monitor the client’s serum creatinine and blood urea nitrogen levels to assess kidney function, but this is not as urgent as evaluating the client for orthostatic hypotension.
Choice B is wrong because checking the client for nasal congestion is not a priority action for a client who received an overdose of valsartan.
Nasal congestion is not a common or serious side effect of valsartan. It is more likely to occur with other types of blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta blockers.
Choice D is wrong because obtaining the client’s laboratory results is not a priority action for a client who received an overdose of valsartan.
Laboratory results may provide useful information about the client’s electrolyte levels, kidney function, liver function, or blood counts, but they are not as important as assessing the client’s vital signs and symptoms of hypotension. The nurse should obtain the laboratory results after stabilizing the client’s blood pressure and ensuring adequate perfusion to the organs.
Correct Answer is B
Explanation
Advance directives are legal documents that allow a person to express their wishes for medical care in case they become incapacitated or unable to communicate. They do not require a lawyer or a notary to be valid, as long as they follow the state laws and are signed by the person and two witnesses.
Choice A is wrong because it implies that legal representation is necessary for advance directives, which is not true.
A social worker can help the client with other resources or support, but not with finding a lawyer for this purpose.
Choice C is wrong because it suggests that advance directives can be verbal, which is not true. Advance directives must be written and signed to be legally binding.
Verbal agreements may not be honored or remembered by the provider or the family.
Choice D is wrong because it implies that advance directives need legal review, which is not true. Advance directives are personal decisions that do not need to be approved by a lawyer or a court.
Legal review may be helpful in some cases, but it is not mandatory or essential.
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