The nurse is caring for clients on a medical floor. Which client should be assessed first?
The hemodialysis client who is experiencing anuria
The client diagnosed with cirrhosis who is complaining of itching
The client diagnosed with peripheral arterial disease who is complaining of pain when walking
The client diagnosed with lupus who is complaining of chest pain
The Correct Answer is D
Choice A reason: Anuria in hemodialysis is expected due to renal failure; it’s not acute unless accompanied by distress, less urgent than chest pain’s potential severity.
Choice B reason: Itching in cirrhosis from bile salts is uncomfortable but not life-threatening, ranking below chest pain, which could indicate critical cardiac or pulmonary issues.
Choice C reason: Pain when walking in PAD (claudication) is chronic and stable, not an immediate threat compared to chest pain, which requires urgent evaluation.
Choice D reason: Chest pain in lupus may signal pericarditis or pleuritis, potentially life-threatening complications, prioritizing assessment for rapid intervention over stable conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: CT scan rapidly detects ischemic stroke or hemorrhage in the brain, critical for numbness, headache, and speech issues, guiding urgent treatment decisions.
Choice B reason: Hemoglobin and hematocrit assess blood count, not brain pathology like stroke, which requires imaging to identify infarction or bleeding, not anemia.
Choice C reason: MRI offers detailed stroke imaging but is slower than CT, less ideal for acute ER settings needing immediate diagnosis of neurological symptoms.
Choice D reason: Pulmonary angiography evaluates lung vessels for embolism, irrelevant to stroke symptoms (numbness, headache, speech difficulty), which localize to brain issues.
Correct Answer is B
Explanation
Choice A reason: Lactulose doesn’t lower glucose; it’s a sugar metabolized by gut bacteria, unrelated to blood sugar control in cirrhosis, where glucose issues stem elsewhere.
Choice B reason: In cirrhosis, lactulose traps ammonia in the gut by acidifying it, promoting excretion and reducing toxic levels that cause hepatic encephalopathy, the primary goal.
Choice C reason: Potassium levels aren’t directly reduced by lactulose; it affects ammonia via gut pH, not electrolytes like potassium, which may rise in renal issues.
Choice D reason: Bicarbonate isn’t targeted by lactulose; it’s a buffer altered in acid-base imbalances, not the focus in cirrhosis where ammonia reduction is critical.
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