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. Correct. Viral pneumonia can be highly contagious, so placing the client in a private room can help prevent the spread of the infection to other patients.
B. Incorrect. Azithromycin is an antibiotic typically used for bacterial infections and would not be indicated for viral pneumonia.
C. Incorrect. Pneumococcal immunization is effective for preventing bacterial pneumonia caused by Streptococcus pneumoniae but is not indicated for viral pneumonia.
D. Incorrect. Limiting fluid intake to 1 L per day is not appropriate for a client with viral pneumonia, as adequate hydration is important for supporting the body's immune response and preventing dehydration.

A. Check the client's ability to use the call light. B. Document the client's risk in the medical record. C. Request a referral for physical therapy. D. Place a gait belt in the client's room.

Correct Answer is A

Explanation

A. "Check the client's ability to use the call light." This is the first action to take because ensuring the client can call for assistance if needed is crucial for their safety. If the client has impaired mobility and is at risk for falls, they should be able to summon help easily if they need to move or if assistance is required.

B. "Document the client's risk in the medical record." While documentation is important, ensuring the client can call for help should be prioritized to address immediate safety needs. Documenting the risk can occur after addressing immediate needs.

C. "Request a referral for physical therapy." While physical therapy may be indicated later, the priority is to ensure the client’s immediate safety by confirming they can call for help if needed.

D. "Place a gait belt in the client's room." A gait belt can be useful for assisting with mobility, but the immediate concern is ensuring the client can call for help if they need it, rather than preparing for assistance with mobility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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