A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
Cellulitis accompanied by a low-grade fever
A decreased level of consciousness and vomiting
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 B
b. A decreased level of consciousness and vomiting
Explanation:
When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.
Explanation for the other options:
a. Cellulitis accompanied by a low-grade fever:
While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.
c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:
Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.
d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:
While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.
In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct technique for using an albuterol MDI involves closing the mouth around the mouthpiece to create a seal. This helps ensure that the medication is delivered directly into the lungs and maximizes its effectiveness. It also helps prevent the medication from escaping and being wasted.
"Exhale immediately after inhaling": This instruction is not accurate. After closing the mouth around the mouthpiece and activating the inhaler to release the medication, the client should inhale slowly and deeply through the mouth, holding their breath for about 10 seconds if possible. Exhaling immediately after inhaling would not allow enough time for the medication to be absorbed effectively.
"Tilt your head forward while inhaling": Tilted head position is not necessary when using an albuterol MDI. The client should hold the inhaler in an upright position, with the mouthpiece directed toward their mouth. This allows for proper delivery of the medication.
"Take three quick breaths while depressing the canister": This instruction is not accurate for using an albuterol MDI. The correct technique involves taking a slow and deep breath in through the mouth, while simultaneously depressing the canister to release the medication. Taking three quick breaths may not allow enough time for adequate medication delivery.
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
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