An older adult client arrives to the emergency department after experiencing two days of fever, nausea, and vomiting. The client gives the nurse a bag of home medications and reports a history of insulin dependent diabetes mellitus with an onset of blurred vision. Which intervention should the nurse implement first?

Establish mental status baseline.

Insert an indwelling urinary catheter.

Check the accuracy of medication list.

Obtain a capillary blood glucose level.

Answer and Explanation

The Correct Answer is D

A.   While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B.   Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C.   Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D.   Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

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Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

A. Presence of rebound phenomenon. B. Limitations to range of motion. C. Muscle strength and tone. D. Degree of neurosensory impairment.

Correct Answer is A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

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Naxlex Comprehensive Predictor Exams

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non- blanchable redness. Which intervention is most important for the nurse to implement for this immobile client?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.