The nurse received shift report on several clients. Which client should the nurse assess first?
A client with post-operative atelectasis who becomes suddenly short of breath
A client with lung cancer who has fatigue, nausea, weight loss, and mild cough
A client with pneumonia is being discharged and needs an influenza vaccination
A client with chronic obstructive pulmonary disease (COPD) with a barrel chest
A client with jugular vein distention and coarse crackles in the lungs.
The Correct Answer is A
Choice A reason: Sudden onset of shortness of breath in a post-operative client is a clinical red flag indicating acute respiratory distress or a potential pulmonary embolism. According to the Airway-Breathing-Circulation (ABC) prioritization framework, this client represents an unstable physiological state requiring immediate assessment and intervention to prevent respiratory failure or cardiac arrest.
Choice B reason: Fatigue, nausea, weight loss, and a mild cough are constitutional and expected symptoms associated with the chronic progression of lung cancer. While these symptoms require management, they are non-urgent and do not indicate an immediate threat to the client's life or airway stability compared to acute dyspnea.
Choice C reason: A client awaiting discharge for an influenza vaccination is considered stable. This is a routine nursing task that falls under health promotion and maintenance rather than acute clinical care. This task should be deferred until all unstable or potentially compromised clients have been thoroughly assessed and stabilized.
Choice D reason: A barrel chest is a chronic structural adaptation in COPD patients resulting from long-term air trapping and hyperinflation of the lungs. It is an expected finding for this diagnosis and does not indicate an acute change in status or a need for emergent nursing intervention or stabilization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Checking for a diaper rash requires undressing the infant and manipulating their limbs, which is highly likely to wake them. In pediatric assessment, intrusive or potentially uncomfortable procedures should always be delayed until the end of the examination to maintain the infant's cooperation and physiological baseline.
Choice B reason: Measuring length involves stretching the infant out on a measuring board, which is a stimulating and often upsetting procedure for a baby. Performing this first would cause the infant to cry, making it impossible to accurately assess heart and lung sounds due to the resulting respiratory and vocal noise.
Choice C reason: The nurse should always perform the least invasive and quietest assessments first while an infant is sleeping. Auscultating the heart, lungs, and abdomen while the child is still allows the nurse to hear clear sounds without the interference of crying, movement, or increased heart and respiratory rates.
Choice D reason: Assessing muscle tone involves manipulating the infant's extremities to check for resistance and recoil. This physical contact is stimulating and will likely disturb the infant's sleep. Like measuring and diaper checks, this should be deferred until the nurse has completed the "quiet" portions of the physical assessment.
Correct Answer is B
Explanation
Choice A reason: Pain typically triggers a sympathetic nervous system response, which results in tachycardia (an increased heart rate) rather than bradycardia. While pain assessment is a standard part of vital sign collection, it is an unlikely cause for a heart rate of 52 beats per minute in an adult.
Choice B reason: Many medications, such as beta-blockers, calcium channel blockers, and digoxin, are designed to slow the heart rate to reduce myocardial oxygen demand. Identifying if the client is taking these substances is a critical assessment step to determine if the bradycardia is a therapeutic effect or a potential toxicity.
Choice C reason: Anxiety, similar to pain, activates the "fight or flight" response, leading to an increase in heart rate and blood pressure. It would be highly unusual for a client experiencing clinical anxiety to present with a resting heart rate of 52, making this assessment less relevant to the finding.
Choice D reason: Intercostal retractions are a sign of severe respiratory distress and increased work of breathing. While the nurse should always monitor respiratory status, retractions are typically associated with airway obstruction or primary lung pathology rather than an isolated finding of a slow, but otherwise stable, heart rate.
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