After change-of-shift report, which patient should the nurse assess first?

Questions 49

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Question 1 of 5

After change-of-shift report, which patient should the nurse assess first?

Correct Answer: C

Rationale: The correct answer is C because the patient with hyperosmolar hyperglycemic syndrome showing signs of poor skin turgor and dry oral mucosa is at risk for severe dehydration and potential complications. Assessing this patient first is crucial to address their immediate needs. Choice A is incorrect as the 19-year-old with possible dawn phenomenon can be assessed after the patient with hyperosmolar hyperglycemic syndrome who is at higher risk. Choice B is incorrect as a blood glucose reading of 230 mg/dL in a 35-year-old with type 1 diabetes is high but not indicative of an immediate life-threatening situation compared to severe dehydration. Choice D is incorrect as the 68-year-old with peripheral neuropathy and foot pain, while in discomfort, does not present an immediate threat to their life like severe dehydration does in a patient with hyperosmolar hyperglycemic syndrome.

Question 2 of 5

When planning care for a client with vision loss, which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Correct Answer: A

Rationale: The correct answer is A: Arrange food in a consistent pattern on the client's plate. This intervention is crucial for a client with vision loss as it helps them locate and distinguish different food items more easily. By arranging food in a consistent pattern, the client can use their sense of touch to identify and pick up each item. Thicking liquids (choice B) does not directly address the issue of feeding difficulties due to vision loss. Providing small-handled utensils (choice C) may help with dexterity but does not specifically address the visual impairment. Assigning a staff member to feed the client (choice D) may not promote independence and may not always be feasible.

Question 3 of 5

A nurse is discussing the responsibility of caring for clients with clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Correct Answer: A

Rationale: The correct answer is A because having family members wear a gown and gloves when visiting a client with C. difficile infection helps prevent the spread of the bacteria to others. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. By wearing protective gear, family members can reduce the risk of spreading the infection to themselves or others. Choice B is incorrect because while cleaning contaminated surfaces with a bleach solution is important, it is not directly related to family members' responsibilities. Choice C is incorrect because alcohol-based hand sanitizers are not effective against C. difficile spores, so proper handwashing with soap and water is recommended. Choice D is incorrect because assigning the client to a room with a private bathroom is not directly related to the responsibility of family members visiting the client.

Question 4 of 5

A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?

Correct Answer: D

Rationale: The correct answer is D: Have a tongue depressor available at the client's bedside. This is important to prevent the client from biting their tongue during a seizure, which can lead to injury or airway obstruction. Placing blankets around the bed (choice A) is not a priority during a seizure. Refraining from using restraints (choice B) is correct, as restraints can cause harm during a seizure. Positioning the client laterally (choice C) is recommended after the seizure has ended, not during the seizure itself.

Question 5 of 5

A registered nurse (RN) who usually uses public transportation has not renewed her driver’s license. During a recent car trip with a friend, she took over driving when her friend became tired. Which of the following is true?

Correct Answer: B

Rationale: The correct answer is B: She may lose her RN license for driving without a license. As a registered nurse, she is held to a high standard of professional conduct. Driving without a valid license is illegal and unethical, potentially endangering herself and others. This behavior could be viewed as a violation of professional ethics, leading to disciplinary action by the licensing board. Choices A, C, and D are incorrect because they do not address the legal and ethical implications of driving without a valid license for a healthcare professional. A nurse should always adhere to legal and ethical standards to maintain the trust and integrity of the profession.

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