A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
A mother who reports that her son vomited after a dose of methylphenidate
A client who has COPD and reports an oxygen saturation of 90%
A client who reports that her new colostomy stoma appears purple
A client who reports feeling a vibration in his new internal arteriovenous graft for dialysis
The Correct Answer is C
The mother reporting vomiting in choice A may be concerning, but it is a known side effect of methylphenidate, and the client should be monitored for any further symptoms. A client who has COPD and reports an oxygen saturation of 90%. An oxygen saturation of 90% in COPD is within normal due to the chronic hypoxia.The purple appearance of a colostomy stoma in choice C may indicate ischemia or necrosis, and is an urgent concern.The feeling of a vibration in a new arteriovenous graft for dialysis in choice D may indicate an arterial steal syndrome, but it is not a medical emergency, and the client can be instructed to follow up with the provider. Therefore, the correct answer is choice B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C because "You should limit your use of extension cords." Extension cords are a common source of electrical hazards and should be used only when necessary. The nurse should advise the client to use power strips with built-in circuit breakers instead of extension cords.
Choice A is wrong because, "You should pull on the cord when unplugging items," is not the correct answer as pulling on the cord can damage the cord and create a hazard. Choice B is wrong because, "You should cover electrical cords with an area rug," is not the correct answer as this can create a trip hazard. Choice D is wrong because, "You should secure extension cords with clear packing tape," is not the correct answer as this does not address the underlying issue of using extension cords unnecessarily.
Correct Answer is B
Explanation
The correct answer is choice B, Initiate a referral for the client to a social worker.
Explanation: The nurse should initiate a referral for the client to a social worker who can assist with financial and social issues related to the client's disability.
Offering to bring groceries to the client or contacting friends and neighbors are not sustainable long-term solutions. Providing information about respite care is not relevant to the client's immediate concern.
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