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 A
Explanation
a. This is the correct answer because maintaining adequate hydration helps prevent nephrotoxicity associated with acyclovir. Encouraging fluid intake during and after the infusion helps flush the drug through the kidneys.
b. While monitoring urinary output is important, it alone may not be sufficient to prevent nephrotoxicity.
c. Providing a low-protein diet is not a standard intervention for preventing acyclovir-induced nephrotoxicity.
d. Administering intravenous normal saline boluses, as ordered, can help maintain hydration and prevent nephrotoxicity. However, encouraging oral fluid intake is a more direct and immediate measure during acyclovir infusion.
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.
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