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.

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Free Nursing Study Resources

Correct Answer is ["10"]

Explanation

Set up the dosage calculation:

Desired dose:5 mg

Available dose:0.5 mg/tablet

We need to find out how many tablets will contain 5 mg of digoxin.

Use the formula:

Number of tablets = Desired dose (mg) / Available dose (mg/tablet)

Plug in the values and calculate:

Number of tablets = 5 mg / 0.5 mg/tablet

Number of tablets = 10 tablets

Round to the nearest whole number:

10 tablets

A. Memory loss B. Dry mouth C. Hypertension D. Urinary retention

Correct Answer is A

Explanation

A) Memory loss:
Zolpidem, a sedative-hypnotic commonly prescribed for insomnia, can cause memory problems, including short-term memory loss. This is a known adverse effect of zolpidem, especially when taken in higher doses or when a person is not able to get a full night’s sleep after taking the medication. This side effect can manifest as amnesia or difficulty recalling events that occurred while under the influence of the medication.

B) Dry mouth:
While dry mouth is a common side effect of many medications, including some antihistamines and antidepressants, it is not a typical or major adverse effect associated with zolpidem. Though less common, it may occur in some individuals, but it is not considered a primary or significant adverse effect of this drug.

C) Hypertension:
Zolpidem does not typically cause hypertension. In fact, it is more likely to cause a calming effect that may lead to a decrease in blood pressure, particularly in individuals who experience sedation. It is important for the nurse to monitor for any unusual changes in vital signs, but hypertension is not a known adverse effect of zolpidem.

D) Urinary retention:
Urinary retention is more commonly associated with medications that affect the autonomic nervous system, such as antihistamines, anticholinergics, or certain opioids. Zolpidem is not typically associated with urinary retention. While any sedative could potentially cause mild disruptions in normal bladder function due to its sedative properties, urinary retention is not a frequent or well-known side effect of zolpidem.

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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 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.)

Correct Answer is ["10"]

Explanation

A nurse is teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem?

Correct Answer is A

Explanation

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