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 B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

A. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." B. "Mass casualty events do not require an increase in the number of staff that are needed." C. "A mass casualty event only occurs within the health care facility and could endanger staff." D. "An event is termed a mass casualty when it overwhelms local medical capabilities." E. "Mass casualty events may require the collaboration of many local agencies to handle the situation."

Correct Answer is ["A","B","C"]

Explanation

Choice A reason: This statement is incorrect because a mass casualty event refers to an incident that results in a large number of casualties, overwhelming the local healthcare system. A fight between visitors in the emergency department, although potentially serious, would not constitute a mass casualty event.

Choice B reason: This statement is incorrect because mass casualty events typically require a significant increase in the number of staff to manage the influx of patients and provide adequate care. Staffing levels are often augmented to ensure that the medical response can meet the demands of the situation.

Choice C reason: This statement is incorrect because mass casualty events are not limited to occurring within healthcare facilities. They can happen anywhere, such as at public events, natural disasters, or terrorist attacks, and involve a large number of casualties that overwhelm local medical resources.

Choice D reason: This statement is correct and does not indicate a need for further teaching. A mass casualty event is indeed characterized by overwhelming local medical capabilities, necessitating additional resources and support.

Choice E reason: This statement is correct and does not indicate a need for further teaching. Mass casualty events often require collaboration among multiple local agencies, such as emergency services, law enforcement, and healthcare providers, to effectively manage the situation.

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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

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

The nurse educator is educating new staff nurses about mass casualty events. Which statements by the new nurse indicate a need for further teaching? (Select All That Apply)

Correct Answer is ["A","B","C"]

Explanation

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The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?

A nurse is assigned to care for four clients. Which client should the nurse assess first?

The nurse educator is instructing newly hired nurses about client rights and the legal obligations of hospital staff. Which of the following would be an example to use when describing an assault in a clinical situation?