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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Lip smacking is not typically associated with pain in newborns and may indicate hunger or a self-soothing behavior.
B. Correct. Diaphoresis, or sweating, can be a sign of pain in newborns following circumcision. C. Incorrect. Hypoglycemia refers to low blood glucose levels and is not a direct manifestation of pain.
D. Incorrect. Transient strabismus, or crossed eyes, is not typically associated with pain in newborns and may be a normal variation.
Correct Answer is D
Explanation
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
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