The nurse comes onto shift. Which client should be assessed first?

Anxious client awaiting a procedure reporting new onset of chest pressure

Angry client dissatisfied with the room and demands to speak to the unit director

Status post surgical client complaining of pain 4/10 at a large incision site

Client admitted with a bowel obstruction who has nausea and vomiting

Answer and Explanation

The Correct Answer is A

A. Anxious client awaiting a procedure reporting new onset of chest pressure: New chest pressure in a client can indicate acute myocardial ischemia or another life-threatening cardiac event. Immediate assessment and intervention are critical to ensure patient safety, making this the highest-priority client. Prompt recognition of potential cardiac compromise is essential to prevent deterioration.

B. Angry client dissatisfied with the room and demands to speak to the unit director: While addressing patient concerns and complaints is important for patient satisfaction and communication, this situation is non-urgent and does not pose an immediate threat to the client’s physiological stability.

C. Status post-surgical client complaining of pain 4/10 at a large incision site: Moderate pain requires timely management to promote comfort and recovery; however, it does not indicate an immediate life-threatening condition. Pain management is important but secondary to acute chest pain.

D. Client admitted with a bowel obstruction who has nausea and vomiting: Nausea and vomiting need assessment and intervention to prevent complications such as dehydration, but unless accompanied by signs of hemodynamic instability or electrolyte imbalance, this is less urgent than acute chest pain signaling potential cardiac compromise.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Right direction: The RN clearly communicates the task (obtain a blood sugar), the specific parameters for reporting results (if below 70 or above 300), and important patient-specific instructions (use the left arm due to dialysis access). This precise instruction exemplifies the right direction, ensuring the UAP understands what is expected and when to notify the RN.

B. Right person: While assigning the task to a UAP implies consideration of the appropriate staff member, the scenario does not provide details about the UAP’s competence, experience, or scope of practice. Therefore, the right person is not explicitly verified in this step.

C. Right supervision: Supervision involves the RN monitoring, evaluating, and providing guidance throughout or after task completion. In this case, the RN only instructs the UAP and specifies reporting criteria but does not describe ongoing supervision, this right is not fully addressed.

D. Right circumstance: The right circumstance involves considering patient stability, complexity of care, and context of the work environment. While the instruction accounts for a dialysis access site, the overall patient condition and risk factors are not fully addressed in this step, the right circumstance is only partially considered.

A. Apply the sensor to the client's sternum B. Place the sensor on the client's right index finger C. Apply the sensor to the client's right great toe D. Place the sensor on the client's earlobe

Correct Answer is D

Explanation

A. Apply the sensor to the client's sternum: The sternum is not a reliable site for standard pulse oximetry because it lacks a strong pulsatile arterial signal. Reflectance sensors can be used on the chest in specific settings, but this is generally less accurate for routine oxygen saturation monitoring compared with peripheral sites with good perfusion.

B. Place the sensor on the client's right index finger: The right index finger is the typical site for pulse oximetry; however, in this client with peripheral vascular disease, slow capillary refill and a weak pulse indicate poor perfusion. Using this site could produce inaccurate readings, including falsely low SpO₂ values or signal loss, making it inappropriate in this situation.

C. Apply the sensor to the client's right great toe: The toe can sometimes be used if upper extremities are unavailable, but peripheral vascular disease may also compromise perfusion in the lower extremities, especially in the presence of arterial disease. This could also result in unreliable readings.

D. Place the sensor on the client's earlobe: The earlobe provides a site with more consistent perfusion that is less affected by peripheral vascular disease. It is suitable for pulse oximetry in patients with weak or compromised distal pulses, allowing accurate measurement of oxygen saturation while bypassing poorly perfused fingers or toes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse comes onto shift. Which client should be assessed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

The following arterial blood gas (ABG) results indicate? pH-7.13 PaCO2-38.8 mmHg PaO2-83 mmHg HCO3-13.2 mEq/L BE-(-14.5) O2 Sat-95%

The nurse is collaborating with the dietitian about a client with a stage 3 pressure ulcer. After the collaboration the nurse orders a meal plan that includes increased

When documenting, what guidelines should be followed? Select all that apply.

The client has a serum potassium level of 3.1 mEq/L. What is a priority intervention?

A Venturi mask is unique from other oxygen delivery methods because it:

A client is post op day 1 for a right knee replacement. The client has severe pain that impairs the ability to walk safely. Which nursing diagnosis takes priority?

A client with a suspected pneumonia presents to the emergency department. Which diagnostic test does the nurse anticipate being ordered for this client?

The nurse is caring for a client that has had a nasogastric tube to low wall suction for 5 days. Which acid/base imbalance would the nurse expect to see in this client?