A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?

A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10

A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3°C (101° F)

A 60-year-old client who has COPD, is receiving O; 2 L/min via a nasal cannula, and has an oxygen saturation of 89%

A 26-year-old female client who has pelvic inflammatory disease and is unable to void

Answer and Explanation

The Correct Answer is C

A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10: While chest pain is concerning, a pain level of 4 is moderate, and the client is hemodynamically stable. This client requires timely assessment but does not present the most immediate threat to life.

B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3°C (101°F): The client has an infection that requires monitoring and treatment, but the fever alone does not indicate an immediate life-threatening condition. Assessment and intervention are important but not emergent.

C. A 60-year-old client who has COPD, is receiving O₂ 2 L/min via a nasal cannula, and has an oxygen saturation of 89%: Hypoxemia is an immediate threat to life. An oxygen saturation below 90% in a client with COPD requires prompt assessment and intervention to prevent respiratory failure, making this the highest priority.

D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void: Urinary retention is uncomfortable and can lead to complications, but it is not immediately life-threatening. This client can be assessed after addressing the client with hypoxemia.

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Correct Answer is A

Explanation

A. Administer an oral rehydration solution: Oral rehydration solutions (ORS) are specifically formulated to replace fluids and electrolytes lost during diarrhea. They are the first-line treatment for mild to moderate dehydration in children with gastroenteritis, helping prevent complications and restore hydration safely.

B. Offer the child 1 cup of chicken broth: While chicken broth provides some fluid, it is not balanced in electrolytes and sodium, and it may be too concentrated in sodium for a preschooler with diarrhea. ORS is more appropriate for correcting dehydration.

C. Encourage the child to eat gelatin: Gelatin is low in electrolytes and protein and does not adequately replace fluids lost from diarrhea. Relying on gelatin alone would not meet the child’s rehydration needs.

D. Initiate a high-carbohydrate diet: High-carbohydrate foods are not recommended during acute diarrhea because they can worsen osmotic diarrhea. Focus should be on fluid and electrolyte replacement rather than high-carbohydrate foods initially.

A. A client who has a burn requiring a sterile dressing change B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds C. A client who received a chemotherapy treatment and reports nausea D. A client who has hypothyroidism and is stuporous

Correct Answer is D

Explanation

A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.

B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.

C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.

D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.

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A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is A

Explanation

A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

Correct Answer is D

Explanation

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