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 A

Explanation

A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.

A. Pallor in the exposed portion of the left foot B. Inability to move the left foot C. Increased warmth of the exposed portion of the left foot D. Ecchymosis in the exposed portion of the left foot E. Paresthesia in the left foot

Correct Answer is ["A","B","D","E"]

Explanation

A. Pallor in the exposed portion of the left foot indicates a possible reduction in blood flow, which is a symptom of compartment syndrome.
B. Inability to move the left foot could suggest nerve damage or significant muscle dysfunction, which are potential consequences of compartment syndrome.
C. Increased warmth of the exposed portion of the left foot is not typically a symptom of compartment syndrome. This condition is more commonly associated with coolness due to impaired blood flow rather than increased warmth.
D. Ecchymosis in the exposed portion of the left foot may be indicative of underlying bleeding or bruising, which can increase compartmental pressure and is a symptom of compartment syndrome.
E. Paresthesia in the left foot, such as tingling or a burning sensation, can be a sign of nerve compression or damage, which is consistent with compartment syndrome.

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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

A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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