The nurse is caring for four different clients. Which of these clients should the nurse assess first?
The client who has a history of rheumatoid arthritis complaining of 5/10 pain in the joints of his hands.
The client who requires a chlorhexidine scrub prior to a double mastectomy this morning.
The client who can have nothing by mouth for a scheduled surgery this morning and received an ordered dose of insulin glargine the night before.
The client who is receiving digoxin with a blood pressure of 100/75 mmHg.
The Correct Answer is D
a) Pain in a client with a history of rheumatoid arthritis is important but may not require immediate attention compared to potential complications of medication administration.
b) Preparing a client for a chlorhexidine scrub is important, but it is not an immediate priority compared to potential complications related to medication and vital signs.
c) A client who cannot have anything by mouth before surgery and received insulin glargine the night before needs monitoring, but it may not require immediate assessment compared to the potential complications of the client receiving digoxin with a blood pressure of 100/75 mmHg.
d) The client receiving digoxin with a blood pressure of 100/75 mmHg is at risk for toxicity, as low blood pressure may increase the concentration of digoxin. This client should be assessed first to prevent potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a) Taking sucralfate with an antacid is not recommended, as antacids can interfere with the effectiveness of sucralfate.
b) Sucralfate should be taken 30 to 60 minutes before meals to ensure optimal binding to the gastric mucosa and to form a protective barrier.
c) Taking sucralfate whenever indigestion occurs may not provide consistent protection, as its effectiveness is enhanced when taken before meals.
d) Taking sucralfate immediately after meals is not recommended, as it may interfere with its ability to form a protective coating on the gastric mucosa.
Correct Answer is B
Explanation
a) Vitamin D levels may be affected by long-term glucocorticoid use, but the described symptoms are more indicative of potential glucocorticoid-related side effects, such as Cushingoid features, which warrant liver function tests.
b) Liver function tests are appropriate to assess the impact of long-term glucocorticoid use on the liver, as these medications can affect liver function.
c) Serum electrolytes are important to monitor, but the specific symptoms mentioned (full cheeks, hump of fat) are not typically associated with electrolyte imbalances.
d) A tuberculin skin test is unrelated to the observed symptoms and is not typically ordered based on the physical features described.
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