A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

A client admitted for a cholecystectomy 2 days ago with decreased bowel sounds.

A client admitted for diabetes mellitus with a blood glucose of 140 mg/dL.

A client admitted for a left femur fracture with new-onset confusion.

A client admitted for dehydration with a BP of 105/77 mm Hg.

Answer and Explanation

The Correct Answer is C

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

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Correct Answer is A

Explanation

Choice A reason: This statement is a priority because testosterone therapy can significantly impact fertility. Clients should be informed about the potential effects on their reproductive health, including the possibility of reduced fertility or infertility. This knowledge allows them to make informed decisions about fertility preservation before starting hormone therapy.

Choice B reason: While an increase in muscle mass is a common and expected effect of testosterone therapy, it is not as critical as discussing the potential impact on fertility. Increased muscle mass is generally seen as a desired outcome for transgender men undergoing hormone therapy.

Choice C reason: Acne is a known side effect of testosterone therapy, but it is not as high of a priority compared to the long-term implications of fertility. Acne can be managed with appropriate skincare and treatment.

Choice D reason: Changes in emotion or mood can occur with hormone therapy, but they are generally considered part of the overall effects of transitioning. These changes are important to monitor but are not as immediately critical as the impact on fertility.

A. Do not allow visiting of the victims until the bodies are prepared. B. Provide privacy for law enforcement to interview the family. C. Provide a calm location for the family to cope and discuss needs. D. Call the hospital chaplain to stay with the family and pray for the deceased.

Correct Answer is C

Explanation

Choice A reason: Restricting visiting of the victims until the bodies are prepared is a procedural step that can be managed without immediate involvement. While it's important, it does not directly address the family's immediate emotional needs.

Choice B reason: Providing privacy for law enforcement to interview the family is necessary for the investigation, but it should not take precedence over addressing the family's immediate emotional distress.

Choice C reason: Offering a calm location for the family to cope and discuss their needs addresses the immediate emotional and psychological support that the family requires in the wake of a traumatic event. It provides them with a safe space to begin processing their grief and start the healing process.

Choice D reason: Calling the hospital chaplain is a valuable step for providing spiritual and emotional support, but the first priority is to offer a calm and safe environment for the family. The chaplain can then be called to assist in this supportive space.

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A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

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