A nurse on a medical unit is planning care for a group of clients.
Which of the following clients should the nurse attend to first?
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%.
A client who has thrombocytopenia and reports a nosebleed.
A client who has left-sided paralysis and slurred speech from a prior stroke.
A client who has multiple sclerosis and reports ataxia and vertigo.
The Correct Answer is B
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first.
Thrombocytopenia is a condition characterized by low platelet count, which increases the risk of bleeding.
A nosebleed can be a sign of significant bleeding, and it is important for the nurse to assess the severity and take appropriate action to stop the bleeding and prevent further complications.
Although the other clients also require nursing care, their conditions are not as urgent as the client with thrombocytopenia and a nosebleed.
The client with chronic obstructive pulmonary disease and an oxygen saturation of 89% may require oxygen therapy or other interventions to improve respiratory function, but the situation is not immediately life-threatening.
The client with left-sided paralysis and slurred speech from a prior stroke may require ongoing care and rehabilitation, but there is no indication of an acute change in their condition.
The client with multiple sclerosis and ataxia and vertigo may require assistance with mobility and balance, but their symptoms do not pose an immediate threat to their health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload.
Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.
Correct Answer is C
Explanation
Colonics, also known as colonic irrigation or colon hydrotherapy, involves flushing the colon with fluids to remove waste and is not recommended for individuals with diverticulitis.
Choice A is wrong because acupuncture is not a contraindication for a client with diverticulitis.
Choice B is wrong because saw palmetto is not a contraindication for a client with diverticulitis.
Choice D is wrong because guided imagery is not a contraindication for a client with diverticulitis.
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