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This is today’s daily nclex snack the nurse receives report on four clients which client should the nurse assess first we know we are being asked a priority question because it says who should the nurse assess first pause the screen and comment your answer below a client who received a dose of nitroglycerin and reports a bad headache so in this question we see
Nitroglycerin which is a vasodilator and a bad headache headaches are a very common side effect of nitroglycerin so this is a normal finding this client is not in immediate danger and doesn’t need to be assessed first a client with pancreatitis who reports pain rating 7 out of 10 and has a heart rate of 98 beats per minute we see pancreatitis and pain pain is very
Common in clients with pancreatitis although we may need to prescribe pain medications to this client they’re not in immediate danger a client who received a thyroidectomy with a temperature of 100.1 fahrenheit and reports feeling anxious this client is showing signs of a thyroid storm after a thyroidectomy thyroid hormone levels remain elevated causing a thyroid
Storm this is an acute life-threatening emergency this client should be seen first but we want to be sure to read all the answer options because there could be a higher priority patient so let’s go to the last one a client with a continuous bladder irrigation who reports bladder spasms bladder spasms can occur when a client has a continuous bladder irrigation it
Could just mean that the solution is too cold but this client is not in immediate danger so the correct answer is number three the nurse should assess the client who appears to be having a thyroid storm first because they are in the most danger and nclex tip for answering priority questions like this is to figure out the expected and unexpected findings in the answer
Options now if they are expected findings we think normal and non-emergent but no these findings may be outside normal limits but are expected for the situation some examples of this would be copd clients typically have oxygen saturation levels that are below normal so it’s expected that they have low oxygen saturation levels so a normal o2 sat is 95 to 100 but in
Copd clients it’s expected or normal that they could have oxygen levels as low as 88 or like in this question a client on nitroglycerin who has a very bad headache this is a normal and non-emergent finding this is an expected side effect if they are unexpected findings we think emergency these clients usually need to be assessed first or have an intervention first
Some examples of unexpected findings would be seeing halos around lights when taking digoxin because this could indicate digoxin toxicity or a patient with head trauma begins projectile vomiting because this could indicate an increased icp or intracranial pressure if you see words like sudden severe and rapid onset think unexpected and emergent that’s all for your
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NCLEX Practice Questions! | FREE Daily NCLEX Snack | NurseInTheMaking By NurseInTheMaking
