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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F"]
Explanation
Choice A reason: Sodium of 130 mEq/L indicates hyponatremia, likely from vomiting-induced sodium loss. This aligns with the child’s electrolyte profile and symptoms, making it a correct imbalance the nurse would identify as most likely based on the lab values and clinical presentation.
Choice B reason: Calcium of 9.5 mg/dL is normal, not indicating hypocalcemia. Hyponatremia and metabolic alkalosis match the labs (sodium 130, HCO3 30), making this incorrect, as it does not reflect the child’s electrolyte imbalances from vomiting and irregular pulse.
Choice C reason: Potassium of 3.3 mEq/L is low, not high, ruling out hyperkalemia. Hyponatremia and metabolic alkalosis fit the labs and vomiting history, making this incorrect, as it contradicts the child’s potassium level in the nurse’s assessment of imbalances.
Choice D reason: Potassium of 3.3 mEq/L suggests mild hypokalemia, but hyponatremia (sodium 130) is more prominent with vomiting. Metabolic alkalosis is also evident, making this partially correct but incorrect as the primary imbalance compared to hyponatremia in the child’s profile.
Choice E reason: HCO3 of 30 mEq/L indicates alkalosis, not acidosis, due to vomiting-induced hydrogen ion loss. Hyponatremia and metabolic alkalosis are correct, making this incorrect, as it contradicts the child’s alkalotic state in the nurse’s evaluation of lab values.
Choice F reason: HCO3 of 30 mEq/L indicates metabolic alkalosis, common with vomiting due to loss of acidic gastric contents. This, with hyponatremia, aligns with the child’s labs and symptoms, making it a correct imbalance the nurse would identify in the assessment.
Correct Answer is B
Explanation
Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.
Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.
Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.
Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.