A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

A decreased level of consciousness and vomiting

Cellulitis accompanied by a low-grade fever

A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago

Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL

Answer and Explanation

The Correct Answer is A

A.   A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B.   Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C.   A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D.   A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.

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Correct Answer is B

Explanation

A. Hemoglobin (Hgb) of 12 g/dL is within the normal range for a pregnant individual and does not typically require notification of the provider.
B. Platelet count of 90,000/mm3 is below the normal range (typically 150,000 to 400,000/mm3) and may indicate thrombocytopenia, which can be associated with conditions such as preeclampsia or HELLP syndrome. The nurse should notify the provider about this result.
C. Hematocrit of 37% is within the normal range for a pregnant individual and does not typically require notification of the provider.
D. Creatinine level of 0.7 mg/dL is within the normal range and does not typically require notification of the provider.

A. Name and medical record number B. Birth date and mother's name C. Age and diagnosis D. Footprints and identification number

Correct Answer is A

Explanation

- Rationale for A: The name and medical record number are unique identifiers that are used to accurately match a newborn with their medical records and ensure that the correct medication is administered. This method of identification minimizes the risk of medical errors, which is crucial in a hospital setting where multiple newborns may be present.

- Rationale for B: While the birth date and mother's name are important, they may not be as effective for identification because multiple newborns could share a birth date, and there could be more than one mother with the same name in the maternity ward.

- Rationale for C: Age and diagnosis are not specific enough for the identification of a newborn when administering medication. Age is not a distinguishing factor in a neonatal unit, and the diagnosis could apply to multiple infants.

- Rationale for D: Footprints and identification number can be used as secondary identifiers. However, footprints may change rapidly as the newborn grows, and the identification number should be cross-referenced with the name and medical record number for accurate identification.

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A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

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Naxlex Comprehensive Predictor Exams

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