Question

A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

Answer 1

Correct Answers:

A client who reports pain in his left calf and has a respiratory rate of 32/min.

Rationale :

🔴 A sudden onset of calf pain and tachypnea suggests a possible deep vein thrombosis (DVT) that may have progressed to pulmonary embolism (PE).

🔴 PE is a life-threatening emergency requiring immediate evaluation and intervention to prevent respiratory collapse.

🔴 The respiratory rate of 32/min is abnormal and indicates increased work of breathing or impaired gas exchange.

🔴 This client should be seen first as prompt diagnosis and treatment can be life-saving.

🔴 Other clients have needs, but they are non-urgent compared to the threat of embolism.

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Answer 2

Correct Answers:

A client who reports pain in his left calf and has a respiratory rate of 32/min.

Rationale :

🟠 Signs of DVT and respiratory distress raise concern for a pulmonary embolism, which is a medical emergency.

🟠 Tachypnea and calf pain are key indicators that require immediate assessment to prevent fatal complications.

🟠 Clients with stable vitals or routine needs can be addressed after emergency threats are ruled out.

🟠 The nurse must prioritize airway and circulation threats first, per ABCs.

🟠 Failure to act swiftly may result in hypoxia or cardiac arrest.

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Answer 3

Correct Answers:

Describe the food placement as though the plate were a clock.

Rationale :

🟡 Using the clock method is a widely accepted nursing strategy to promote independence in visually impaired clients.

🟡 This technique enhances the client's ability to self-feed without assistance, fostering dignity and autonomy.

🟡 The method is also simple, effective, and requires no assistive devices.

🟡 Adaptive utensils may help with motor control, but knowing where food is located is the first priority.

🟡 Discouraging conversation can affect social well-being, and feeding by staff should only occur if the client is unable.

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Answer 4

Correct Answers:

The stoma is pinkish red.

Rationale :

🟢 A healthy colostomy stoma should appear pink to red, indicating good vascular perfusion.

🟢 This color suggests the tissue is alive and functioning, which is critical in early postoperative assessment.

🟢 Pale, cyanotic, or dusky stomas suggest ischemia and require immediate intervention.

🟢 Other signs like bowel sounds and flatus may take several days to return, especially after abdominal surgery.

🟢 The nurse should prioritize stoma assessment as a key indicator of colostomy viability.

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Answer 5

Correct Answers:

Wear an N95 mask when in the client's room.

Rationale :

🔵 Pertussis is transmitted via droplets, but due to the forceful coughing, N95 masks offer better protection.

🔵 The nurse must prevent inhalation of aerosolized respiratory droplets by using a fit-tested respirator.

🔵 While a gown protects against contact, respiratory protection is the priority with pertussis.

🔵 Negative pressure rooms are unnecessary, as pertussis is not airborne like tuberculosis.

🔵 Proper PPE ensures the safety of healthcare workers and prevents transmission to others.

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Answer 6

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🟣 Put on gloves and cleanse the site—Always start with hand hygiene and cleansing to prevent infection.

🟣 Pull skin laterally 1 inch—This is essential for creating the Z-track path that seals medication in muscle.

🟣Insert the needle into the muscle at 90° after skin is pulled and site prepped.

🟣 Aspirate and inject the medication if no blood appears during aspiration.

🟣 Remove the needle and release tissue to complete the injection and allow the skin to cover the medication path.

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Answer 7

Correct Answers:

"I will have my potassium level checked periodically."

Rationale :

🟤 Hypokalemia increases the risk of digoxin toxicity, which can lead to life-threatening arrhythmias.

🟤 Monitoring serum potassium and maintaining it within normal range is essential during therapy.

🟤 Clients should also report signs like blurred vision, nausea, and confusion, which may indicate toxicity.

🟤 Taking antacids may reduce digoxin absorption and should be spaced apart by at least 2 hours.

🟤 Daily weights are important in heart failure, but potassium monitoring is most directly related to digoxin safety.

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Answer 8

Correct Answers:

"I will eat fish three times a week."

Rationale :

⚫ Fish, especially fatty fish like salmon or mackerel, is rich in omega-3 fatty acids, which reduce cardiovascular risk.

⚫ Replacing red meat with fish helps lower saturated fat intake, which is crucial in coronary artery disease.

⚫ Eating fish 2–3 times weekly aligns with AHA recommendations for heart-healthy eating.

⚫ 2% milk is higher in fat; skim or plant-based alternatives are better.

⚫ Coconut oil contains saturated fats and is discouraged in low-fat diets.

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Answer 9

Correct Answers:

Uses a beclomethasone inhaler.

Rationale :

⚪ Long-term use of inhaled corticosteroids like beclomethasone can lead to bone demineralization.

⚪ This increases the risk of osteoporosis and fractures, especially in postmenopausal women.

⚪ Other factors like sedentary lifestyle or poor calcium intake can compound the risk.

⚪ The other choices (sardines, estrogen, walking) are protective factors against osteoporosis.

⚪ Education about bone health and medication risks is key.

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Answer 10

Correct Answers:

Rifampin

Rationale :

🟥 Rifampin, an antitubercular drug, is well-known to cause red-orange discoloration of body fluids, including urine.

🟥 This effect is harmless but alarming to patients if they’re not educated in advance.

🟥 The nurse must inform clients to expect changes in urine, sweat, tears, and even contact lenses.

🟥 Furosemide causes diuresis, not discoloration. Isoniazid may cause liver issues, not color change.

🟥 Metoprolol does not alter urine color and is used for hypertension and angina.

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QLexNursing

1 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

2 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

3 :
A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?

5 :
A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is preparing to administer ceftriaxone using the Z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, what is the correct sequence the nurse should use to administer the medication?

7 :
A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching with a client who has coronary artery disease and is to begin a low-fat diet. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

10 :
A nurse is reviewing the medical record of a client who reports his urine is red orange. The nurse should identify which of the following medications can cause this adverse effect?

QLexNursing

1 : A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

2 : A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

3 : A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

4 : A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?

5 : A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?

6 : A nurse is preparing to administer ceftriaxone using the Z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, what is the correct sequence the nurse should use to administer the medication?

7 : A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is reinforcing teaching with a client who has coronary artery disease and is to begin a low-fat diet. Which of the following statements by the client indicates an understanding of the teaching?

9 : A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

10 : A nurse is reviewing the medical record of a client who reports his urine is red orange. The nurse should identify which of the following medications can cause this adverse effect?

1 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

2 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

3 :
A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates the colostomy is functioning properly?

5 :
A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?

6 :
A nurse is preparing to administer ceftriaxone using the Z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, what is the correct sequence the nurse should use to administer the medication?

7 :
A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is reinforcing teaching with a client who has coronary artery disease and is to begin a low-fat diet. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

10 :
A nurse is reviewing the medical record of a client who reports his urine is red orange. The nurse should identify which of the following medications can cause this adverse effect?