The nurse has arrived for the scheduled shift. After receiving bedside report and making the initial rounds on the assigned clients, which client should the nurse plan to care for first?
Client who is ambulatory demonstrating a steady gait
Client scheduled for physical therapy for the first crutch-walking session
Postoperative client who has just received an opioid pain medication
Client with onset of new chest pain
The Correct Answer is D
Choice A reason: Client who is ambulatory demonstrating a steady gait is not a priority for the nurse. This client is stable and does not require immediate intervention.
Choice B reason: Client scheduled for physical therapy for the first crutch-walking session is not a priority for the nurse. This client is not in acute distress and can wait for the physical therapist to assist them.
Choice C reason: Postoperative client who has just received an opioid pain medication is not a priority for the nurse. This client is expected to have pain relief from the medication and can be monitored for adverse effects later.
Choice D reason: Client with onset of new chest pain is the priority for the nurse. This client is potentially experiencing a life-threatening condition such as a myocardial infarction or a pulmonary embolism. The nurse should assess the client's vital signs, oxygen saturation, and electrocardiogram, and administer oxygen, nitroglycerin, and aspirin as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement indicates the need for further teaching, as it shows that the client does not understand the possible complication of postherpetic neuralgia, which is a chronic pain condition that can persist for months or years after the rash heals. The nurse should explain to the client that some people may experience this condition and that there are treatments available to manage the pain.
Choice B reason: This statement does not indicate the need for further teaching, as it shows that the client understands the importance of preventing the transmission of the virus to others, especially those who have not had chicken pox or the vaccine. The nurse should reinforce this behavior and remind the client to cover the rash with a dressing and avoid contact with pregnant women, newborns, and immunocompromised people.
Choice C reason: This statement does not indicate the need for further teaching, as it shows that the client knows the etiology of the infection. The nurse should confirm that the client is correct and explain that the virus remains dormant in the nerve cells after the initial infection and can reactivate later in life due to stress, aging, or other factors.
Choice D reason: This statement does not indicate the need for further teaching, as it shows that the client recognizes the prodromal symptom of the infection. The nurse should acknowledge that the client is correct and explain that the pain is caused by the inflammation of the nerve fibers where the virus resides. The nurse should also ask the client about the severity and frequency of the pain and provide appropriate interventions.
Correct Answer is B
Explanation
Choice A reason: Institute of Medicine (IOM) research is not a method for developing procedures, but an organization that conducts health-related studies and provides recommendations for improving health care quality and safety.
Choice B reason: Evidence-based practice is the correct method for developing procedures. It is the process of integrating the best available research evidence with clinical expertise and patient preferences to make decisions about health care.
Choice C reason: Knowledge, skills, and attitude are not a method for developing procedures, but the components of competency that nurses need to provide safe and effective care.
Choice D reason: Core measures are not a method for developing procedures, but a set of standardized performance indicators that evaluate the quality of care for specific conditions or procedures.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.