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 D

Explanation

Choice A reason: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

A. Shortness of breath. B. Lightheadedness. C. Dry cough. D. Bitter taste in the mouth.

Correct Answer is B

Explanation

Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.

Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.

Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.

Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.

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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

Correct Answer is D

Explanation

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

Correct Answer is B

Explanation

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?