Which of the following clients should be considered a priority for immediate assessment and intervention?
A client who has epidural analgesia and weakness in the lower extremities
A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%).
A client who has sinus arrhythmia and is receiving cardiac monitoring.
A client who has a hip fracture and a new onset of tachypnea.
The Correct Answer is D
A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.
B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.
C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.
D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
Correct Answer is A
Explanation
A. Bradypnea: Hypermagnesemia depresses neuromuscular and central nervous system function, which can lead to slowed respiratory rate (bradypnea) and potentially respiratory failure in severe cases.
B. Personality change: Personality changes are more commonly associated with hyponatremia, hypernatremia, or other electrolyte imbalances affecting the brain, rather than hypermagnesemia.
C. Seizure: Seizures are more likely in hypomagnesemia due to increased neuromuscular excitability, not in hypermagnesemia, which generally causes neuromuscular depression.
D. Elevated hematocrit: Hypermagnesemia does not directly affect red blood cell concentration or hematocrit levels. Changes in hematocrit are usually related to fluid volume status, not magnesium levels.
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