The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

A 47-year-old who had a colon resection yesterday and is reporting pain

A 20-year-old 2 days postoperative who refuses to ambulate

A newly admitted 88-year-old with a 2-day history of vomiting and loose stools

A 60-year-old who is 3 days post-myocardial infarction and has been stable

Answer and Explanation

The Correct Answer is C

Choice A reason: Postoperative pain in a 47-year-old is concerning but not immediately life-threatening unless severe or accompanied by other symptoms (e.g., hemorrhage). Pain management is important, but fluid and electrolyte imbalances from vomiting and diarrhea in an elderly client pose a greater immediate risk, requiring urgent assessment.

Choice B reason: Refusal to ambulate in a 20-year-old postoperative client risks complications like thrombosis but is not an acute emergency. Immobility requires intervention, but dehydration and electrolyte imbalances in an elderly client with vomiting and diarrhea are more urgent, as they can rapidly lead to life-threatening hypovolemia.

Choice C reason: An 88-year-old with vomiting and diarrhea for 2 days is at high risk for dehydration, electrolyte imbalances, and hypovolemia, especially given age-related reduced physiological reserves. This can lead to shock or organ failure, making it the highest priority for immediate assessment to stabilize fluid and electrolyte status.

Choice D reason: A stable 60-year-old post-myocardial infarction client is not an immediate priority unless new symptoms arise. Stability suggests no acute changes in cardiac status. Vomiting and diarrhea in an elderly client pose a greater immediate risk due to potential rapid deterioration from fluid loss.

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Correct Answer is C

Explanation

Choice A reason: Supine with head elevated is used for comfort or respiratory support but not for lumbar puncture. This position does not allow access to the lumbar spine or flex the back to open intervertebral spaces, which is necessary for safe needle insertion during the procedure.

Choice B reason: Prone with legs extended is used for procedures like wound care but not lumbar puncture. This position does not flex the spine to widen intervertebral spaces, making needle insertion difficult and risky. The lateral recumbent position is standard for accessing the subarachnoid space.

Choice C reason: Lateral recumbent with knees flexed maximizes lumbar spine flexion, opening intervertebral spaces for safe needle insertion into the subarachnoid space during a lumbar puncture. This position reduces the risk of nerve damage and ensures accurate cerebrospinal fluid collection, making it the standard choice.

Choice D reason: Sitting upright with back straight may be used in some procedures but is less common for lumbar puncture. It does not provide optimal spinal flexion compared to the lateral recumbent position, which better exposes the lumbar vertebrae, reducing complications during needle insertion.

A. Chest X-ray B. Electrocardiogram (ECG) C. CT pulmonary angiography D. Arterial blood gas (ABG)

Correct Answer is C

Explanation

Choice A reason: A chest X-ray may show secondary signs like atelectasis in pulmonary embolism but is not specific for diagnosis. It primarily rules out other conditions like pneumonia. Pulmonary embolism requires visualization of a clot, which X-rays cannot provide, making them insufficient for confirming the diagnosis.

Choice B reason: An ECG may show tachycardia or right heart strain in pulmonary embolism but is not diagnostic. It detects cardiac changes secondary to the embolism, not the clot itself. Specific imaging, like CT angiography, is needed to visualize the pulmonary artery obstruction for confirmation.

Choice C reason: CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism, as it directly visualizes thrombi in pulmonary arteries using contrast-enhanced imaging. It confirms the presence, location, and extent of the clot, enabling rapid diagnosis and treatment to prevent life-threatening complications like right heart failure.

Choice D reason: Arterial blood gas may show hypoxemia or respiratory alkalosis in pulmonary embolism due to impaired gas exchange but is not diagnostic. It reflects physiological changes, not the clot itself. Imaging, like CT angiography, is required to confirm the presence of a pulmonary artery obstruction.

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The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a lumbar puncture. Which position should the nurse place the client in to facilitate the procedure?

Correct Answer is C

Explanation

A nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic test is most likely to confirm this diagnosis?

Correct Answer is C

Explanation

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery method is most appropriate for this client?

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply)

As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?

A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

A nurse is working with an older adult and educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears disengaged and states, “I’m just too old to learn.” What would be most appropriate for the nurse to do to motivate this client?

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

A nurse is teaching a client with hypertension about dietary modifications. Which recommendation is most appropriate to reduce blood pressure?