A nurse in a medical-surgical unit is caring for six clients.
Complete the following sentence by using the list of options.
The first client the nurse
... [Show More] should assess is _____ followed by _____.
Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a
history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client
is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous
administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart
failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is
admitted with a new diagnosis of diabetes mellitus. - Correct Answer (1):
Client 3
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the priority client to assess. The client has an oxygen saturation
that is less than the expected reference range, which is an indication of hypoxia.
Correct Answer (2):
Client 4
When using the airway, breathing, circulation approach to client care, the nurse should
determine that this client is the next priority client to assess. The client has a potassium level
that is less than the expected reference range, which places the client at risk for dysrhythmias.
Incorrect Answers (1):
Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein
is greater than the expected reference range, which is an indication of inflammation.
However, there is another client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level
is greater than the expected reference range, which places them at risk for coronary heart
disease. However, there is another client the nurse should assess first.
Incorrect Answers (2):
Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less
than the expected reference range, which places them at risk for delayed wound healing.
However, this client is not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated
hemoglobin level is greater than the expected reference range, which indicates poor diabetic
control. However, this client is not the next priority client to assess.
A nurse is caring for a client who has COPD.
Select the 3 findings that require follow-up.
Breath sounds
Blood pressure
Oxygen saturation
Temperature
Heart rate - Correct Answer:
Breath Sounds
Crackles are caused by mucous in the airways and are a manifestation of pneumonia.
Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse.
Oxygen Saturation
The client's oxygen saturation is below the expected reference range of 95% to 100%,
indicating hypoxia, and requires follow-up by the nurse.
Temperature
The client's temperature is greater than the expected reference range, indicating an infection,
and requires follow-up by the nurse.
Incorrect Answer:
Blood pressure is incorrect. The client's blood pressure is within the expected reference range
and does not require follow-up by the nurse.
Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to
100/min and does not require follow-up by the nurse.
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.
Based on the client's clinical findings, which of the following actions should the nurse t [Show Less]