The nurse cares for a group of clients. Which client should the nurse prioritize?

A client who needs assistance ambulating in the hall

A client with pain 4/10 requesting pain medication

A client with a scheduled wound dressing change

A client with a change in their level of consciousness

Answer and Explanation

The Correct Answer is D

A. A client who needs assistance ambulating in the hall: Helping with ambulation is important to prevent falls, but it does not indicate an immediate threat to life or safety. This task can be delegated or scheduled after addressing higher-priority needs.

B. A client with pain 4/10 requesting pain medication: Moderate pain requires timely management to promote comfort, but it is not an urgent threat to physiologic stability. Pain management can follow assessment of clients with acute changes.

C. A client with a scheduled wound dressing change: Routine wound care is necessary for healing and infection prevention, but it is a planned intervention that does not indicate an urgent change in status. It can be scheduled after clients with acute concerns are addressed.

D. A client with a change in their level of consciousness: Altered mental status can indicate hypoxia, infection, intracranial pathology, or metabolic disturbance. This represents an immediate, potentially life-threatening change and requires rapid assessment and intervention.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale:

• Blood pressure of 120/82 mmHg: This blood pressure reading is within normal limits for an older adult. While hypotension or significant hypertension may indicate post-operative complications, a reading of 120/82 mmHg does not suggest immediate risk. It is unlikely to represent a complication and is considered stable.

• Body mass index of 26.6: A BMI of 26.6 falls into the overweight category but does not represent an acute post-operative complication. While elevated BMI may contribute to long-term risk factors, it does not indicate an immediate issue following knee replacement surgery.

• Respiration rate of 26 breaths per minute: Tachypnea in a post-operative client may indicate early hypoxia, pulmonary embolism, atelectasis, or pneumonia. After knee replacement surgery, immobility increases the risk of pulmonary complications. Monitoring respiratory status is critical because early detection of pulmonary compromise can prevent severe outcomes.

• Heart rate of 115 beats per minute: Tachycardia can be a compensatory response to hypoxia, pain, anxiety, or early infection. In post-operative clients, elevated heart rate may also indicate blood loss, dehydration, or pulmonary embolism. Continuous monitoring is warranted because persistent tachycardia can precede hemodynamic instability.

• Oxygen saturation of 88% on room air: An oxygen saturation below 90% is clinically significant hypoxemia. After orthopedic surgery, hypoxemia may result from anesthesia effects, atelectasis, or pulmonary embolism. Immediate interventions, such as supplemental oxygen and monitoring for respiratory compromise, are essential.

A. Kussmaul respirations B. Cheyne-Stokes respirations C. Agonal breathing D. Biot's respirations

Correct Answer is B

Explanation

A. Kussmaul respirations: These are deep, rapid, and labored respirations typically associated with metabolic acidosis, such as diabetic ketoacidosis. They do not include alternating periods of apnea and hyperventilation, so they do not match the described pattern.

B. Cheyne-Stokes respirations: This breathing pattern is characterized by cyclic periods of increasing and decreasing depth of respiration, followed by temporary apnea. It commonly occurs in clients with advanced heart failure, neurological injury, or nearing end-of-life, making it consistent with hospice clients exhibiting irregular breathing.

C. Agonal breathing: Agonal respirations are irregular, gasping breaths often seen in severe hypoxia or near death. They are typically ineffective for gas exchange and not part of a regular cyclical pattern.

D. Biot's respirations: Biot’s respirations consist of groups of quick, shallow breaths followed by irregular pauses. They are usually associated with increased intracranial pressure or medullary damage rather than end-of-life breathing patterns.

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The nurse cares for a group of clients. Which client should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Review the electronic health record. For each assessment finding, click to specify whether the finding is a likely complication or unlikely complication.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse cares for a hospice client who exhibits irregular breathing patterns, alternating between periods of apnea and hyperventilation. What breathing pattern should the nurse document?

Correct Answer is B

Explanation

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