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A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
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The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A client
- A. admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer.
- B. admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating.
- C. with pneumonia is ambulating around the nursing unit while wearing a surgical mask.
- D. receiving oxygen via nonrebreather and has an oxygen saturation of 92%.
Correct Answer: D
Rationale: Oxygen saturation of 92% on a nonrebreather (D) indicates inadequate oxygenation, requiring immediate follow-up to adjust oxygen or assess for deterioration. Wheezing during albuterol (A), oxygen use before eating (B), and masked ambulation (C) are expected or less urgent.
The nurse is gathering evidence for a quality improvement committee focused on fall prevention. To provide the highest quality scholarly evidence, the nurse plans on gathering findings from
- A. expert opinions.
- B. randomized controlled trials (RCTs).
- C. C. quantitative studies.
- D. D. qualitative studies.
Correct Answer: B
Rationale: Randomized controlled trials (B) provide the highest level of evidence for fall prevention due to their rigorous methodology. Expert opinions (A), quantitative studies (C), and qualitative studies (D) are lower in the evidence hierarchy.
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.