After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

A client who has a history of pancreatitis and reports severe abdominal pain

A client who has heart failure and reports severe dyspnea

A client who is scheduled for abdominal surgery in 1 hr

A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Answer and Explanation

The Correct Answer is B

A.   While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B.   Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C.   While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D.   While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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Correct Answer is B

Explanation

A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.

A. "You will receive an injection of contrast dye during the test." B. "Consume a clear liquid breakfast on the day of the procedure." C. "Someone should drive you home after the procedure." D. "You will have to drink a contrast medium before the test."

Correct Answer is D

Explanation

A. Incorrect. Upper gastrointestinal series typically involve oral ingestion of a contrast medium, not an injection.
B. Incorrect. Clients are usually instructed to fast before an upper gastrointestinal series, not consume breakfast.
C. Incorrect. While it's generally advisable to have someone accompany the client for procedures involving sedation or anesthesia, fluoroscopy itself does not usually require sedation, and the client can typically drive home afterward.
D. Correct. Prior to an upper gastrointestinal series, clients are usually required to drink a contrast medium to outline the digestive tract for fluoroscopy imaging.

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After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?

Correct Answer is D

Explanation

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