The night nurse on a medical floor has just received report on several patients. On which of the following clients should the nurse make rounds FIRST?
The 78-year-old male with a diagnosis of chronic kidney disease who has developed a new nonproductive cough and is short of breath
The 37-year-old female diagnosed with cellulitis of the left leg yesterday who is experiences warmth in the affected left leg
The 70-year-old male who underwent a transurethral resection of the prostate (TURP) yesterday and is having a burning sensation during urination
The 52-year-old female with pancreatitis who is experiencing abdominal pain rated 7 on a 1-10 scale
The Correct Answer is A
A. The 78-year-old male with chronic kidney disease who develops a new nonproductive cough and shortness of breath is concerning for pulmonary edema or fluid overload, which can rapidly progress and require immediate attention.
B. The 37-year-old female with cellulitis is experiencing warmth in the affected leg, which is expected with cellulitis and may indicate the need for monitoring but is not as urgent as the other options.
C. The 70-year-old male who underwent a TURP is having a burning sensation during urination, which is a common postoperative finding and is not as concerning unless other complications arise.
D. The 52-year-old female with pancreatitis and abdominal pain rated 7 is in pain but is stable, and this pain can typically be managed with pain medication and monitoring, so she is not the most urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Drawing daily labs: This is a clinical task that requires specialized knowledge and skills and should not be delegated to UAP.
B. Transport the urine specimen to the lab: This is a non-clinical task that UAP can perform.
C. Provide perineal care with soap and water around a urinary catheter: UAP can assist with perineal care as it is a routine task that does not require clinical judgment.
D. Insert the foley catheter: Inserting a Foley catheter is a sterile procedure requiring clinical expertise and cannot be delegated to UAP.
E. Assist the incontinent patient to the commode at regular intervals: UAP can assist with toileting and incontinence care.
Correct Answer is D
Explanation
A. Irritability is a common side effect of steroids but is not the most concerning.
B. Headaches can occur with steroid use, but they are not as urgent unless associated with severe symptoms.
C. Weight loss is not a common concern with steroids, as they usually cause weight gain.
D. High blood pressure is a serious side effect of steroid use and should be addressed promptly to avoid cardiovascular complications.
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