After receiving the change-of-shift report, which client does the nurse assess first?

A 45-year-old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

A 57-year-old receiving IV diuretics whose blood pressure is 88/52 mm Hg.

A 67-year-old with nausea and vomiting who reports abdominal cramps.

A 77-year-old with normal saline infusing at 150 mL/hr with an average hourly urine output.

Answer and Explanation

The Correct Answer is B

Choice A reason: Dry mucosa and thirst suggest dehydration, but hypotension (88/52) is more life-threatening. Low blood pressure requires immediate assessment, making this incorrect, as it’s less urgent than the nurse’s priority to address the client with critical hemodynamic instability.

Choice B reason: A blood pressure of 88/52 mm Hg in a client on IV diuretics indicates severe hypotension, a life-threatening condition requiring immediate assessment. This aligns with prioritization in acute care, making it the correct client for the nurse to assess first post-shift report.

Choice C reason: Nausea, vomiting, and cramps are concerning but less urgent than hypotension (88/52), which risks organ perfusion. Low blood pressure is critical, making this incorrect, as it’s secondary to the nurse’s priority of assessing the client with unstable vitals.

Choice D reason: Normal saline at 150 mL/hr with adequate urine output is stable. Hypotension (88/52) is more critical, making this incorrect, as it’s a lower priority compared to the nurse’s need to assess the client with life-threatening low blood pressure first.

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Correct Answer is D

Explanation

Choice A reason: Cough suppressants may reduce discomfort but don’t address hypoxia risk during thoracentesis in COPD exacerbation. Oxygen application ensures safety, making this incorrect, as it doesn’t prioritize respiratory support needed for the client undergoing a procedure affecting lung function.

Choice B reason: A prone position is unsafe for thoracentesis, which requires an upright or side-lying position to access pleural fluid. Oxygen supports breathing, making this incorrect, as it risks procedural complications compared to ensuring oxygenation for the COPD client’s safety.

Choice C reason: Arterial blood gases post-procedure assess respiratory status but aren’t the primary safety intervention during thoracentesis. Oxygen prevents hypoxia, making this secondary and incorrect compared to the immediate need for respiratory support in the COPD client undergoing the procedure.

Choice D reason: Applying oxygen via nasal cannula ensures adequate oxygenation during thoracentesis, critical for a COPD client with exacerbation prone to hypoxia. This aligns with procedural safety protocols, making it the correct intervention to maintain client safety during the pleural fluid removal.

A. Administer morphine 5 mg intravenously. B. Administer a tetanus immunization. C. Assist the client to cough and deep breathe. D. Listen to breath sounds.

Correct Answer is D

Explanation

Choice A reason: Morphine for pain is important but secondary to assessing airway and breathing in burns, as chest involvement risks respiratory compromise. Listening to breath sounds ensures stability, making this incorrect, as it’s less urgent than the nurse’s priority of respiratory assessment.

Choice B reason: Tetanus immunization prevents infection but is not urgent in acute burn management. Breath sounds assess respiratory status, critical with chest burns, making this incorrect, as it’s secondary to the nurse’s first action of ensuring airway and breathing stability.

Choice C reason: Coughing and deep breathing support respiratory function but assume stable breathing. Listening to breath sounds confirms airway patency in chest burns, making this incorrect, as it’s less immediate than the nurse’s priority of assessing respiratory status first.

Choice D reason: Listening to breath sounds is the first action to assess for respiratory compromise in deep partial thickness chest burns, as restlessness may indicate hypoxia. This aligns with burn care priorities, making it the correct action for the nurse to take initially.

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After receiving the change-of-shift report, which client does the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

Correct Answer is D

Explanation

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Correct Answer is D

Explanation

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

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After receiving the change-of-shift report, which client does the nurse assess first?

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