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) Bradycardia is not typically associated with long-term steroid use; it may be more related to factors like anesthesia or surgical stress.
B) Prolonged steroid use increases the risk of thrombosis, and postoperative blood clots are a concern in individuals with a history of long-term steroid use.
C) Steroids can delay wound healing, but in this context of emergency surgery for a ruptured appendix, the primary concern is often the risk of blood clots.
D) Pre-surgical dehydration is a potential concern but is not specifically related to the client's history of steroid use.
Correct Answer is C
Explanation
a) Mentioning respiratory depression is not directly addressing the reported need for increased pain relief and might cause unnecessary concern about a side effect.
b) Accusing the client of addiction without further assessment or consideration of medical guidance is not appropriate and may damage the therapeutic relationship.
c) Developing tolerance to opioids is a common phenomenon, and discussing an increase in dosage with the healthcare provider is a reasonable response.
d) Advising the client to take the medication more often without consulting the healthcare provider can lead to unsafe practices and is not recommended.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.