The nurse has just received the shift report. Which client should the nurse assess first?

The client with a C-6 spinal cord injury who has autonomic dysreflexia

The client with Huntington's disease who has writhing, twisting movements of the face

The client with Guillain-Barré syndrome has ascending paralysis to the knees.

The client with Parkinson's disease who is experiencing a "pill rolling" tremor

Answer and Explanation

The Correct Answer is A

Autonomic dysreflexia is a life-threatening neurological emergency occurring in spinal cord injuries at T-6 or above. It involves uninhibited sympathetic discharge triggered by noxious stimuli, causing extreme hypertension and potential cerebral hemorrhage. Immediate nursing intervention focuses on elevating the head and removing the triggering stimulus, such as a distended bladder.

Rationale:

A. This client is the priority due to the risk of status epilepticus or stroke from hypertensive crisis. Autonomic dysreflexia requires immediate vasodilation and assessment of the urinary or bowel systems. The nurse must act fast to prevent permanent neurological damage or sudden cardiovascular collapse.

B. Huntington's disease involves progressive neurodegeneration characterized by chorea, which are involuntary, jerky movements. While these symptoms are distressing and increase metabolic demands, they are expected findings in the middle stages of the disease. This client does not require immediate, life-saving stabilization over others.

C. Guillain-Barre syndrome involves demyelination causing ascending weakness, which is currently only at the knees. While the nurse must monitor for respiratory failure, the paralysis has not yet reached the diaphragm or intercostal muscles. This client is stable but requires frequent neurological checks throughout the shift.

D. The "pill-rolling" tremor is a classic, rhythmic resting tremor associated with dopamine depletion in the basal ganglia. It is a hallmark sign of Parkinson's disease and does not indicate acute physiological distress. This client’s needs are chronic in nature and do not take priority over emergency conditions.

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Correct Answer is ["B","D"]

Explanation

Closed-loop communication via the read-back process mitigates sentinel events by ensuring the receiver accurately transcribes and interprets critical information provided by the prescriber. This intervention prevents misinterpretation of sound-alike medications or decimal point errors.

Rationale:

A. Computerized systems utilize electronic entry to minimize human error associated with illegible handwriting. Read-back is specifically reserved for oral communication sequences rather than digital transcriptions. Automated systems provide real-time clinical decision support and alerts.

B. Verbal and telephone prescriptions carry a high risk for transcription errors. The nurse must document the prescription and then read back the complete order to the provider. This step confirms the accuracy of the verbal data.

C. Written or printed results provide a physical or digital record that can be visually verified. Read-back is a verbal validation tool; written documents require different safety checks, such as double-verifying patient identifiers and signatures.

D. Receiving a critical result verbally necessitates immediate verification to prevent diagnostic delays. Performing a read-back ensures the nurse has captured the exact value and patient identity correctly. This is a Joint Commission safety standard.

E. Unit secretaries lack the clinical license to receive or transcribe medication prescriptions. Only qualified professionals, such as registered nurses or pharmacists, may accept verbal orders to ensure appropriate clinical judgment and safety.

Correct Answer is ["1.5"]

Explanation

Step 1: Calculate total daily dose
Total daily dose = 48 × 4
= 192 mg/day

Step 2: Determine dose per administration
Every 8 hours = 3 doses/day
Dose per dose = 192 ÷ 3
= 64 mg

Step 3: Convert mg to mL
Volume (mL) = 64 ÷ 43
≈ 1.49 mL

Step 4: Round to the nearest tenth
≈ 1.5 mL

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The nurse has just received the shift report. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

A nurse is preparing to administer gentamicin 4 mg/kg/day IM divided in equal doses every 8 hr to a client who weighs 48 kg. Available is gentamicin injection 43 mg/mL. How many mL should the nurse administer per dose? Round to the tenths place.

Correct Answer is ["1.5"]

Explanation

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