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 A
Explanation
The correct answer is Choice A because, "Describe the place where you are currently living." Asking the client to describe their living situation will provide the case manager with information about the client's home environment and help identify any potential barriers to safe care. This information can then be used to develop a safe and effective discharge plan, which may include arranging for a special bed at home.
Choice B is wrong because, "Apply moisture barrier ointment three times a day," is not the correct answer because it focuses on a specific aspect of the client's care, rather than considering the broader context of their living situation. Choice C is wrong because, "Eat a balanced diet with high-protein snacks," is not the correct answer as it also focuses on the client's care, rather than their living situation. Choice D is wrong because, "A social worker can help you with the cost of supplies," is not the correct answer as it may not be the most pressing concern at the time of discharge planning.
Correct Answer is D
Explanation
The correct answer is choice D, analyzing findings from a facility tabletop disaster simulation. A tabletop exercise is a comprehensive method to test the disaster plan by simulating a disaster scenario in a non-threatening environment, allowing for the identification of strengths and weaknesses in the plan and the development of improvements. Option A assesses only the knowledge of staff members, but does not test the application of the plan in a disaster. Option B focuses on discussing disaster scenarios without testing the ability to apply the plan. Option C only evaluates staff's response to a disaster drill, which is not an ideal method for testing the plan's effectiveness since it is not a real disaster scenario. Therefore, analyzing findings from a facility tabletop disaster simulation is the most comprehensive method to determine the effectiveness of the disaster plan.
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