Difficulty: Medium
Average Score: 65%
Simulated
Passage / Scenario
Nurses' NotesVital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
A nurse is assisting in the care of a female client.
Complete the following sentence by using the lists of options: The nurse should first address the client ___ followed by the client's ___.
Correct answer
A,D
Rationale
Sure, here is the detailed explanation for the correct answer :
1. **Blood pressure (A)**: The nurse should first address the client's blood pressure as it is a vital sign that provides immediate information about the client's cardiovascular health and overall perfusion status.
2. **Potassium level (D)**: Following the assessment of blood pressure, addressing the client's potassium level is important as potassium imbalances can have critical implications on cardiac function and require prompt intervention.
**Summary**:
- **Incorrect Choices**:
- B: Hgb level and F: Hct level are related to blood components and not typically the first priority in a general assessment.
- C: Temperature is important but may not be the immediate priority compared to blood pressure and potassium level.
- E: Abdominal findings are important but may not be the initial focus in this context.
- **Correct Choices**:
- A: Blood pressure and D: Potassium level are crucial in
1. **Blood pressure (A)**: The nurse should first address the client's blood pressure as it is a vital sign that provides immediate information about the client's cardiovascular health and overall perfusion status.
2. **Potassium level (D)**: Following the assessment of blood pressure, addressing the client's potassium level is important as potassium imbalances can have critical implications on cardiac function and require prompt intervention.
**Summary**:
- **Incorrect Choices**:
- B: Hgb level and F: Hct level are related to blood components and not typically the first priority in a general assessment.
- C: Temperature is important but may not be the immediate priority compared to blood pressure and potassium level.
- E: Abdominal findings are important but may not be the initial focus in this context.
- **Correct Choices**:
- A: Blood pressure and D: Potassium level are crucial in