You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

A patient with a fractured femur who is receiving a dose of opioid pain medication and reports a pain level of 8/10.

A patient who has just returned from a colonoscopy and is stable but complaining of minor bloating.

A patient with newly diagnosed Type 1 diabetes who is receiving insulin for the first time and reports confusion.

A patient with a history of heart failure who has a blood pressure of 90/60 mmHg and is lethargic.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pain of 8/10 is significant, but the patient is receiving opioids, and pain is less immediately life-threatening than hypotension and lethargy. This is incorrect, as it’s lower priority than the nurse’s need to address a patient with unstable vital signs.

Choice B reason: Minor bloating post-colonoscopy is expected and stable, not requiring immediate intervention. Hypotension in heart failure is critical, making this incorrect, as it’s less urgent than the nurse’s priority to manage a patient with potential decompensation.

Choice C reason: Confusion in new Type 1 diabetes may indicate hypoglycemia, but hypotension and lethargy in heart failure suggest acute decompensation, a higher priority. This is incorrect, as it’s less critical than the nurse’s focus on the heart failure patient’s instability.

Choice D reason: Hypotension (90/60 mmHg) and lethargy in a heart failure patient indicate possible cardiogenic shock, requiring immediate intervention. This aligns with prioritization in acute care, making it the correct patient for the charge nurse to prioritize for urgent assessment and action.

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Correct Answer is B

Explanation

Choice A reason: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.

Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.

Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.

Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.

A. Neck veins are now distended in the sitting position. B. Breath sounds can be heard in the right lower lung lobe. C. Weight is unchanged from that obtained yesterday. D. Nose and ears have a slightly yellow-tinged appearance.

Correct Answer is A

Explanation

Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.

Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.

Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.

Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.

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You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation?

Correct Answer is B

Explanation

Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Correct Answer is A

Explanation

A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?