At the beginning of the shift, in which order of priority should the practical nurse (PN) assess these four clients? (Arrange from highest priority first to lowest priority last.)
An adult client with an ulcer whose hemoglobin is 9.5 grams/dL.
A young adult with a history of asthma whose arterial pH is 7.48.
An adult woman with vomiting whose potassium is 2.8 mEq/L.
An older adult with dizziness whose O2 saturation is 86%
The Correct Answer is D,C,B,A
A. An adult client with an ulcer whose hemoglobin is 9.5 grams/dL: A hemoglobin of 9.5 indicates mild anemia, which is important to monitor but is not immediately life-threatening in a stable client. This assessment is lower priority compared with acute electrolyte or oxygenation issues.
B. A young adult with a history of asthma whose arterial pH is 7.48: A slightly alkalotic pH may indicate mild respiratory alkalosis. While it requires monitoring, the client is stable and not in immediate distress, making this a moderate priority.
C. An adult woman with vomiting whose potassium is 2.8 mEq/L: Hypokalemia at this level is moderate to severe and increases the risk of cardiac arrhythmias. Prompt assessment and intervention are needed, placing this client higher in priority.
D. An older adult with dizziness whose O₂ saturation is 86%: Hypoxemia is the highest priority because low oxygen saturation can rapidly compromise organ function and may be life-threatening. Immediate assessment and intervention are required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Put the foam toothette between the lips: Using a toothette helps with oral hygiene, but if the client is at risk for aspiration, placing it in the mouth without proper positioning could allow fluids to enter the airway.
B. Position an emesis basin under the chin: An emesis basin is useful for catching secretions, but it does not prevent aspiration. The client must first be positioned safely to reduce the risk of choking.
C. Place the client in a side-lying position: Positioning the client on their side helps maintain airway patency and allows oral secretions to drain, reducing the risk of aspiration during oral care. This is the priority action before performing oral hygiene.
D. Insert an oral airway into the oropharynx: An oral airway is used to maintain airway patency in unconscious clients, but it is not required solely for safe oral care and may cause trauma if inserted unnecessarily. Positioning first is safer.
Correct Answer is D
Explanation
A. Hemorrhage: Hemorrhage involves active bleeding from a surgical site, often characterized by bright red blood and hemodynamic instability. The presence of bowel protruding through the incision indicates a more severe structural complication rather than simple bleeding.
B. Dehiscence: Dehiscence refers to partial or total separation of wound layers, often presenting with serosanguinous drainage. However, it does not involve protrusion of internal organs. When the bowel is visible externally, it indicates progression beyond dehiscence.
C. Infection: Infection may cause redness, warmth, swelling, and purulent drainage at the surgical site but does not result in the exposure of internal viscera. The sudden appearance of bowel tissue points to a mechanical wound failure, not an infectious process.
D. Evisceration: Evisceration is the protrusion of internal organs, such as the bowel, through a surgical incision following wound separation. It is a surgical emergency requiring immediate intervention to cover the exposed organs with a sterile, moist dressing and notify the surgeon promptly.
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