A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
Client reports that her new colostomy stoma appears purple.
Client who has COPD and reports an oxygen saturation of 90.
Client reports feeling a vibration in his new internal arteriovenous graft for dialysis.
Mother reports that her son vomited after a dose of methylphenidate.
The Correct Answer is A
A stoma that turns dark red, purple, or even black in color can be a sign of a problem with blood supply to the stoma 1. This can be a serious issue that requires immediate medical attention.
Choice B is not the correct answer because an oxygen saturation of 90 for a client with COPD is within an acceptable range.
Choice C is not the correct answer because feeling a vibration in a new internal arteriovenous graft for dialysis is not necessarily a cause for immediate concern.
Choice D is not the correct answer because vomiting after a dose of methylphenidate may be a side effect of the medication and may not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This statement suggests that the client may have a problem with their peripheral vision or neck mobility, which should be assessed further by the nurse.
Choice A, “Prepare my medications for the week on Sundays,” is not a cause for concern as it shows that the client is organized and proactive in managing their medications.
Choice B, “Prepare all of my own meals,” is also not a cause for concern as it shows that the client is independent and capable of taking care of their nutritional needs.
Choice C, “Need to change my hearing aid battery weekly,” is not a cause for concern as it is a routine maintenance task for those who use hearing aids.
Correct Answer is A
Explanation
Reviewing how the staff implements the plan during a hands-on practice drill is the most comprehensive method for the nurse to use to determine the effectiveness of the disaster plan. This allows the nurse to observe how well the staff understands and follows the plan in a simulated disaster situation.
Choice B is not the best answer because using inservices to have the staff discuss various disaster scenarios does not provide a comprehensive evaluation of the effectiveness of the plan.
Choice C is not the best answer because testing staff to determine their knowledge of the principles of the plan only assesses their theoretical understanding and does not evaluate their ability to implement the plan in practice.
Choice D is not the best answer because analyzing findings from a facility tabletop disaster simulation only provides a limited evaluation of the effectiveness of the plan.
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