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 multiple sclerosis and reports ataxia and vertigo

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%

A client who has left-sided paralysis and slurred speech from a prior stroke

A client who has thrombocytopenia and reports a nosebleed

Answer and Explanation

The Correct Answer is D

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

A. Administer proparacaine eyedrops into the affected eye. B. Instill 0.9% sodium chloride solution into the affected eye. C. Collect information about the irritant that caused the injury. D. Place a strip of pH paper onto the cul-de-sac of the affected eye.

Correct Answer is C

Explanation

The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.

Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

Correct Answer is C

Explanation

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