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%

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Tell the resident and the UAP that shouting is not permitted: While setting behavioral limits is important, addressing both parties simultaneously does not stop the immediate verbal conflict or protect the resident from potential emotional harm.

B. Enter the room and tell the UAP to leave the room immediately: The priority is to protect the resident from verbal abuse and de-escalate the confrontation. Removing the UAP stops the conflict, ensures the resident’s emotional safety, and allows the PN to assess the resident’s condition and provide reassurance.

C. Tell both of them to lower their voices in consideration of other residents: Asking them to quiet down minimizes the impact on others but fails to address the abusive nature of the exchange. The situation requires immediate intervention to stop the staff’s inappropriate behavior.

D. Report the incident and the UAP for further action by the nurse-manager: Reporting is necessary and should occur after the immediate threat has been resolved. The PN should first stop the confrontation and protect the resident before following up with appropriate documentation and notification to the nurse-manager.

A. Advise the UAP to wash hands before providing further care. B. Determine if the UAP was wearing gloves when providing care. C. Instruct the UAP to return to the client's room to wash hands. D. Remind the UAP to use an alcohol-based hand rub regularly.

Correct Answer is C

Explanation

A. Advise the UAP to wash hands before providing further care: While reminding the UAP to wash hands before assisting another client is important, the immediate concern is that the UAP may have left the client’s room without performing proper hand hygiene, which risks cross-contamination.

B. Determine if the UAP was wearing gloves when providing care: The use of gloves does not replace the need for proper hand hygiene. Even if gloves were worn, hands must still be washed after glove removal to prevent the spread of pathogens.

C. Instruct the UAP to return to the client's room to wash hands: Directing the UAP to perform hand hygiene immediately after client contact ensures compliance with standard precautions and protects other clients from contamination.

D. Remind the UAP to use an alcohol-based hand rub regularly: Regular use of alcohol-based sanitizer is encouraged, but in this case, the PN should ensure immediate corrective action rather than provide a general reminder. The focus must be on stopping the current breach of infection control.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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