After a change-of-shift report, which client should the nurse assess first?

A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain

A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL

A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%

Answer and Explanation

The Correct Answer is B

A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.

While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.

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Correct Answer is B

Explanation

In a child with acute appendicitis, it is common to observe an elevated white blood cell count (WBC) as a response to the infection or inflammation associated with the condition. The neutrophil count may be within the lower end of the normal range or slightly decreased, as it can be affected by the severity and duration of the appendicitis. The red blood cell count (RBC) appears to be within the normal range. The lactic acid level is normal, indicating no significant metabolic acidosis.

A. Deficient intake of protein. B. Administration of hypotonic IV fluids. C. Excessive dietary intake of salt. D. Overdose of supplemental Potassium pills.

Correct Answer is B

Explanation

A likely cause of a low sodium level (hyponatremia) of 128 mEq/L is the administration of hypotonic IV fluids. Hypotonic IV fluids have a lower concentration of solutes compared to the body's fluids, which can lead to dilutional hyponatremia. When these fluids are administered, they can cause water to move into the cells, diluting the sodium concentration in the bloodstream.

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After a change-of-shift report, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing the patient's laboratory values?

Correct Answer is B

Explanation

A client's Sodium level is 128 meq/L. The nurse knows that a likely cause of this lab finding is:

Correct Answer is B

Explanation

A client is admitted with Diabetic Ketoacidosis (DKA). The client asks the nurse "Why did this happen? I have been taking my insulin as prescribed and following my diet carefully" The nurse reviews the client's chart and realizes that this emergency may be related to which common causes of DKA?

A student nurse correctly explains the pathophysiology of celiac when it is stated that patients who have celiac disease:

The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

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What are the most important nursing interventions for clients with possible renal calculi? List two.

The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

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A patient is receiving Gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition?