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 C

Explanation

A. Constipation is not a common or expected side effect of cefazolin and is not typically associated with this medication.
B. Elevated skin patches are not a known side effect of cefazolin and would not typically occur as a result of taking this medication.
C. Ringing in the ears (tinnitus) is a potential adverse effect of cefazolin and should be reported to the provider because it may indicate ototoxicity, which can be serious.
D. Depression is not a common side effect of cefazolin and is not typically associated with this medication.

A. Lip-smacking B. Stiff posture C. Weak cry D. Tongue-darting

Correct Answer is C

Explanation

A. Lip-smacking may indicate hunger or a desire to feed but is not necessarily indicative of pain in a newborn with shoulder dystocia.
B. Stiff posture may indicate discomfort or distress, but it is not specific to pain and can be caused by various factors.
C. A weak cry can be a sign of pain or distress in newborns. It may indicate that the newborn is experiencing discomfort related to the shoulder dystocia.
D. Tongue-darting is a normal reflex in newborns and is not typically associated with pain.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct Answer is C

Explanation

A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?

Correct Answer is C

Explanation

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