A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?

A client who has type 2 diabetes mellitus needs assistance counting the carbohydrates in her meal.

A client who has a new tracheostomy is experiencing coughing episodes.

A client who has a BMI of 17 refuses his dinner tray.

A client awaiting discharge needs to demonstrate colostomy care before leaving.

Answer and Explanation

The Correct Answer is B

A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.

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Correct Answer is B

Explanation

A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.

A. A client who has dementia and is experiencing paranoia B. A client who has a UTI and reports itching after receiving a dose of cefaclor PO C. A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr D. A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Correct Answer is D

Explanation

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

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A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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