A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who has dehydration with a urine output of 40 mL/hr.
A client who has cancer and reports pain as 4 on a scale of 0 to 10.
A client who has asthma and a respiratory rate of 40/min.
A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.
The Correct Answer is C
Choice A rationale:
Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.
Choice B rationale:
Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.
Choice C rationale:
(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.
Choice D rationale:
A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. List of community resources.
Choice A rationale:
Emergency contact information is typically found in the patient’s admission records or demographic section, not in the discharge summary.
Choice B rationale:
Intake and output summary is part of the daily nursing notes or fluid balance chart, not usually included in the discharge summary.
Choice C rationale:
The discharge summary often includes a list of community resources to support the patient after discharge, such as contact information for follow-up care, support groups, or home health services.
Choice D rationale:
Basic demographic data is recorded in the patient’s initial admission records and is not typically repeated in the discharge summary.
Correct Answer is C
Explanation
Choice A rationale:
Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.
Choice B rationale:
Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.
Choice C rationale:
Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.
Choice D rationale:
Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.
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