After receiving morning report about four clients, which client should the nurse attend to first?

An older female client who had a hip replacement yesterday and is notably pale with a Hemoglobin of 10.5 g/dl.

An adult client with osteomyelitis of the ankle who refuses an IV restart that is needed to administer antibiotics.

An elderly client with low back pain who removed the pelvic traction and repeatedly states a strong desire to go home.

A young adult client with a closed reduction of a fractured femur who has been complaining of increasingly severe pain.

Answer and Explanation

The Correct Answer is D

Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

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Correct Answer is C

Explanation

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

A. A room that contains very little furniture. B. A room that has at least two other clients assigned to it. C. A quiet room away from the nurse's station. D. A bright-colored room located near the recreation room.

Correct Answer is C

Explanation

A. A minimally furnished room may be beneficial for safety, but it is not the primary consideration for room assignment.
B. A room with multiple roommates may increase stimulation, which can worsen manic symptoms.
C. A quiet room away from the nurse's station helps reduce environmental stimuli, which can help manage the client's elated state.
D. A bright-colored room near the recreation area may increase sensory stimulation, potentially worsening manic symptoms.

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After receiving morning report about four clients, which client should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Correct Answer is C

Explanation

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

Correct Answer is C

Explanation

When conducting diet teaching for a client diagnosed with hypokalemia, which foods should the nurse encourage the client to eat?

The healthcare provider prescribes amoxicillin-clavulanic acid suspension 300 mg by mouth (PO) three times daily (TID) for a child with a lower respiratory infection. The bottle is labeled," 250 mg/5 mL. How many mL should the nurse administer in a single dose? (Enter numeric value only.)

A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

The nurse is caring for a client diagnosed with type 1 diabetes mellitus who uses both short-acting and long-acting insulin adjusted doses throughout the day. Which nutrient is essential for the client to count for each meal and snacks?

A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent's suicide attempt, which question is most important for the nurse to ask the family?