A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

A client who has early dementia and awoke confused to their location this morning

A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning

A client who has pneumonia and has developed wheezing

A client who is postoperative and has a urine output of 50 mL for the past 3 h

Answer and Explanation

The Correct Answer is C

A) A client who has early dementia and awoke confused to their location this morning:
Confusion in a client with early dementia could indicate a range of possible causes, such as infections, medication side effects, or changes in routine. However, while this warrants investigation, confusion alone does not represent an immediate life-threatening situation according to the ABCDE priority framework. The focus is on managing airway, breathing, circulation, and disability issues first.

B) A client who is scheduled for discharge and has a 38.4°C (101.1°F) temperature this morning:
A fever may indicate infection, which would require further assessment and potentially treatment. While this is a concern, it does not immediately threaten the client's airway, breathing, or circulation. Since the client is not in an acute crisis and is scheduled for discharge, this would be a lower priority compared to clients with more urgent issues like breathing problems or insufficient urine output.

C) A client who has pneumonia and has developed wheezing:
Wheezing indicates potential airway constriction, which could impair the client's breathing. Given that breathing difficulties are a primary concern in the ABCDE priority framework (Airway, Breathing, Circulation, Disability, and Exposure), this client requires immediate attention. Pneumonia combined with wheezing can signify a worsening respiratory condition, which poses an acute risk to the client's oxygenation and overall stability.

D) A client who is postoperative and has a urine output of 50 mL for the past 3 hours:
Oliguria (low urine output) postoperatively is concerning, as it may indicate kidney dysfunction, hypovolemia, or other complications. While it is an important issue that requires attention, it is not immediately life-threatening unless the client shows signs of worsening shock or kidney failure. However, given that this issue does not immediately affect the client’s airway or breathing, it is a lower priority than the client with pneumonia and wheezing.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

A. use hot water so rinse hand sanitizer off B. Dry hands with a reusable towel. C. Rub hands together 20 seconds, D. Rub hand sanitizer around rings on fingers.

Correct Answer is D

Explanation

A) Use hot water so rinse hand sanitizer off:
Using hot water is not recommended when performing hand hygiene with alcohol-based hand sanitizer. Alcohol-based sanitizers do not require rinsing off, as they are designed to evaporate quickly, killing germs as they dry. Rinsing with water, especially hot water, can dilute the sanitizer, reducing its effectiveness. Hands should be left to dry naturally after applying the sanitizer.

B) Dry hands with a reusable towel:
While towels can be used for drying hands after washing with soap and water, they should not be used after alcohol-based hand sanitizers. Alcohol hand sanitizers should be allowed to air dry on the hands. Using a towel could reintroduce contaminants and diminish the effectiveness of the sanitizer. Ideally, hands should be rubbed together until they are dry without the need for any towel.

C) Rub hands together for 20 seconds:
Alcohol-based hand sanitizers are effective in killing germs in a short amount of time—usually within 20 seconds or less. However, the correct technique for using alcohol-based hand sanitizers involves rubbing hands together until they are completely dry, not for a full 20 seconds as one might with handwashing. The important factor is ensuring the sanitizer has covered all surfaces of the hands, including between fingers and around nails, before allowing it to air dry.

D) Rub hand sanitizer around rings on fingers:
Rubbing the hand sanitizer around rings is a necessary step. Jewelry, such as rings, can harbor bacteria or other pathogens, making it essential to ensure the sanitizer comes into contact with areas that are often missed during hand hygiene, like around rings. The nurse should rub the hand sanitizer thoroughly over all surfaces of the hands, including around jewelry, to ensure effective hand hygiene.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is preparing to perform hand hygiene with an alcohol based hand sanitizer. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a terminal diagnosis and states, ‘’I am ready to update my will. " The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?

A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number, Use leading zero if it applies. Do not use a trailing zero.)

A nurse is reviewing the medical history of a client who is luted for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?