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 B
Explanation
The correct answer is Choice B because "Provide a smoking cessation class." Secondary prevention activities aim to detect and treat a disease in its early stages. In the case of smoking cessation classes, it is a secondary prevention activity because it aims to detect and treat the harmful effects of smoking before it progresses to a more serious condition such as lung cancer or chronic obstructive pulmonary disease.
Choice A is wrong because, "Advocate for laws that prohibit texting while driving," is not the correct answer because it is an example of primary prevention, which aims to prevent the onset of a disease or injury. Choice C is wrong because, "Refer a client who is recovering from a substance use disorder to a social service program," is an example of tertiary prevention, which aims to prevent complications or further progression of a disease. Choice D is wrong because, "Encourage a pregnant client to participate in prenatal care," is also an example of primary prevention, which focuses on preventing the onset of a disease or condition.
Correct Answer is C
Explanation
The correct answer is Choice C because, "Evaluate the client's home environment." Since the client has a new prosthesis, the priority is to evaluate the client's home environment for safety and accessibility. Collaborating with a prosthetist to teach the client about care of the prosthesis (Choice A is wrong because) is important, but not the priority at this stage. Determining eligibility for a skilled nursing facility (Choice B is wrong because) and asking about insurance coverage for home health services (Choice D is wrong because) are important considerations, but not the priority assessment in this situation.
Choice A is wrong because: Collaborating with a prosthetist to teach the client about care of the prosthesis is important, but not the priority at this stage.
Choice B is wrong because: Determining whether the client is eligible to go to a skilled nursing facility is an important consideration, but not the priority assessment in this situation.
Choice D is wrong because: Asking about insurance coverage for home health services is an important consideration, but not the priority assessment in this situation.
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