A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10.

A client who received parenteral cephalosporin and reports urticaria and edema.

A client who is being admitted with bilateral stage 3 pressure injuries on both heels.

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F).

Answer and Explanation

The Correct Answer is B

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

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

Explanation

Choice A Reason:

Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.

Choice B Reason:

Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.

Choice C Reason:

Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.

Choice D Reason:

Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.

Choice E Reason:

Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.

A. Infection B. Vomiting C. Widening pulse pressure D. Equal and reactive pupils E. Intracranial pressure reading of 10 mm Hg

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

Explanation

Choice A Reason:

Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.

Choice B Reason:

Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.

Choice C Reason:

Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.

Choice D Reason:

Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.

Choice E Reason:

An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.

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A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

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

Explanation

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

Explanation

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