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 D

Explanation

A. Amniotic fluid color: While the color of amniotic fluid can provide important information about fetal well-being and possible complications, the priority immediately following an amniotomy is to assess the fetal heart rate to ensure fetal well-being and monitor for any signs of fetal distress.
B. The client's temperature: While maternal temperature should be monitored regularly during labor to detect signs of infection, it is not the priority immediately following an amniotomy. Fetal well-being takes precedence.
C. Frequency of contractions: Monitoring the frequency of contractions is important for assessing progress in labor and identifying any abnormalities, but it is not the priority immediately following an amniotomy. Fetal well-being should be assessed first.
D. Fetal heart rate: Following an amniotomy, the priority is to assess the fetal heart rate to ensure that the umbilical cord has not prolapsed and that the fetus is not experiencing distress due to changes in amniotic fluid volume or other factors related to the amniotomy. Monitoring fetal heart rate allows for early detection of any signs of fetal distress and prompt intervention if needed.

A. A client who has a new onset of chest pain B. A client who has a tracheostomy C. A client who is receiving enteral feedings D. A client who has urinary retention

Correct Answer is A

Explanation

A. A client who has a new onset of chest pain requires immediate assessment and intervention by an RN or healthcare provider with appropriate training and licensure due to the potential seriousness of the condition. Assessing and managing chest pain typically involves performing an ECG, administering medications, and coordinating further diagnostic tests or interventions, which are typically within the scope of practice of an RN or higher.
B. A client who has a tracheostomy may require routine tracheostomy care and suctioning, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.
C. A client who is receiving enteral feedings may require monitoring of feeding tube placement, administration of enteral feedings, and assessment for complications related to enteral nutrition, which are within the scope of practice of an LPN.
D. A client who has urinary retention may require urinary catheterization or bladder scan assessment, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.

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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

A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

Correct Answer is D

Explanation

A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

Correct Answer is A

Explanation

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