The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

A client admitted with a bowel obstruction and is ambulating in the hallway demonstrating a steady gait.

A client admitted with renal colic who had just received morphine 4 mg IV as prescribed.

A client admitted with an infected wound on their right foot, a white blood cell count of 14,000/mm³, and a temperature of 37.7°C.

A client admitted with a tibia fracture scheduled to begin physical therapy with their first crutch walking session.

Answer and Explanation

The Correct Answer is B

Choice A reason: This client, although admitted with a bowel obstruction, is currently demonstrating a steady gait while ambulating, suggesting that they are stable at the moment.

Choice B reason: This client is the priority because they have just received morphine, which requires close monitoring for potential adverse effects, such as respiratory depression. Morphine is a potent opioid, and its administration necessitates vigilant observation to ensure the client's safety.

Choice C reason: While the client with an infected wound and an elevated white blood cell count and temperature requires attention for infection management, the immediate risk of adverse effects from morphine administration takes precedence.

Choice D reason: This client, scheduled to begin physical therapy, is stable enough to participate in planned rehabilitation activities, making them a lower priority compared to the client who has just received a potent opioid.

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Correct Answer is D

Explanation

Choice A reason: A client who had open reduction and internal fixation of a femur fracture 3 days ago is likely to need ongoing monitoring and care to ensure proper healing and prevent complications. Discharging this client could risk worsening their condition or causing new issues to arise.

Choice B reason: A client admitted last night with community-acquired pneumonia is still in the early stages of treatment and may require close observation and medication adjustments to effectively manage their condition and prevent deterioration.

Choice C reason: An older adult client in the observation unit for evaluation of chest pain may still be at risk for serious conditions such as a heart attack. Releasing this client without a definitive diagnosis or proper management plan could endanger their health.

Choice D reason: A client on the medical unit for wound care for a stage 2 wound to the lower extremity is generally considered stable and appropriate for discharge, provided they have the necessary support and resources to continue wound care at home. This client does not require intensive monitoring or treatment that would necessitate hospital admission.

A. A client admitted for a cholecystectomy 2 days ago with decreased bowel sounds. B. A client admitted for diabetes mellitus with a blood glucose of 140 mg/dL. C. A client admitted for a left femur fracture with new-onset confusion. D. A client admitted for dehydration with a BP of 105/77 mm Hg.

Correct Answer is C

Explanation

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

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The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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