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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Insulin aspart: Insulin aspart is a rapid-acting insulin that can be mixed with certain types of insulin, such as NPH insulin, to provide both rapid and intermediate-acting coverage in a single injection.
B. Regular Insulin: Regular insulin is a short-acting insulin that can be mixed with intermediateacting insulins, such as NPH insulin, to provide both short and intermediate-acting coverage in a single injection.
C. Insulin glargine: Insulin glargine is a long-acting insulin that should not be mixed with other insulins due to its pH and precipitation properties.
D. Insulin detemir: Insulin detemir is a long-acting insulin that should not be mixed with other insulins due to its pH and precipitation properties.
E. Insulin lispro: Insulin lispro is a rapid-acting insulin that can be mixed with certain types of insulin, such as NPH insulin, to provide both rapid and intermediate-acting coverage in a single injection
Correct Answer is A
Explanation
A. Switch to a soy-based formula: Bloody stools in infants can be indicative of a cow's milk protein allergy or intolerance. Switching to a soy-based formula may alleviate symptoms in such cases.
B. Switch to a goat's milk formula: Goat's milk is not recommended for infants as it lacks essential nutrients and can lead to nutritional deficiencies and other health issues.
C. Switch to an unpasteurized milk formula: Unpasteurized milk poses a risk of bacterial contamination and is not recommended, especially for infants who are more susceptible to infections.
D. Switch to a condensed milk formula: Condensed milk is not suitable as a primary source of nutrition for infants and does not address the potential underlying issue of cow's milk intolerance.
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