Which patient should the nurse assess first after receiving a change-of-shift report?

A patient with a scheduled physical therapy session in 1 hour.

A patient with a routine follow-up appointment for a non-urgent condition.

A patient with altered mental status and confusion.

A patient with moderate pleuritis and requesting pain medication.

Answer and Explanation

The Correct Answer is C

A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.

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Correct Answer is D

Explanation

A. Tympany upon chest percussion is typically associated with the presence of air, such as in cases of pneumothorax or gastric distention. It is not a typical finding in pneumonia.
B. Unequal pupils (anisocoria) are not a common symptom of pneumonia and may indicate a neurological issue rather than a respiratory infection.
C. Hypertension is not a characteristic finding in community-acquired pneumonia. Pneumonia may cause changes in blood pressure, but hypotension or normal blood pressure is more likely.
D. Confusion is a common finding in older adults with pneumonia. This can be due to factors such as hypoxia, dehydration, or infection-related changes in mental status, often referred to as "pneumonia delirium" or "acute confusion." Older adults are particularly susceptible to cognitive changes due to infection.

Correct Answer is ["28"]

Explanation

Total volume (mL) Drop factor (gtt/mL) = Total drops

1000 mL 10 gtt/mL = 10,000 drops

Next, we need to determine the total number of minutes in 6 hours:

6 hours 60 minutes/hour = 360 minutes

Finally, we can calculate the drip rate:

Drip rate (gtt/min) = Total drops / Total minutes

Drip rate = 10,000 drops / 360 minutes ≈ 28 gtt/min

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Which patient should the nurse assess first after receiving a change-of-shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Correct Answer is ["28"]

Explanation

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Which patient should the nurse assess first after receiving a change-of-shift report?

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