A nurse has just received the morning change of shift report for four clients. Which of the following clients has the highest priority need?
A client who has a serum potassium level of 5 mEq/L and is scheduled for dialysis in the afternoon.
A client who returned 1 hour ago from lithotripsy and is reporting nausea.
A client who had a total abdominal hysterectomy 2 days ago and is reporting a pain level of 3 on a scale of 0 to 10.
A client who has an indwelling urinary catheter and has a total urine output of 80 mL over the past 8 hours.
The Correct Answer is D
Choice A reason: While a serum potassium level of 5 mEq/L is at the higher end of the normal range, the client is scheduled for dialysis, which should address the issue.
Choice B reason: Nausea after lithotripsy is a concern, but it may not be as urgent as other conditions.
Choice C reason: A pain level of 3 is manageable and not the highest priority compared to other more acute needs.
Choice D reason: A urine output of 80 mL over 8 hours is significantly low and could indicate acute kidney injury or urinary retention, which requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A sore throat is a common and expected finding after a bronchoscopy due to the irritation caused by the procedure.
Choice B reason: The presence of a gag reflex is a normal finding and indicates that the reflex has returned after the procedure.
Choice C reason: A blood pressure of 110/78 mm Hg is within the normal range and does not need to be reported.
Choice D reason: Facial edema is not a typical finding after a bronchoscopy and could indicate an allergic reaction or other complication.
Correct Answer is C
Explanation
Choice A reason: Including 2 percent milk in the diet is not the best option for a low-fat diet as it still contains more fat than skim milk.
Choice B reason: Egg whites are a good source of protein and contain no fat, making them suitable for a low-fat diet, so eliminating them is not necessary.
Choice C reason: Eating fish, especially fatty fish rich in omega3 fatty acids, is recommended for a heart-healthy diet and is consistent with the guidelines for a low-fat diet.
Choice D reason: Coconut oil is high in saturated fat and is not recommended for a low-fat diet.
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