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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Storing items on the steps can create a tripping hazard, especially for a client recovering from hip arthroplasty.

Choice B reason: Placing electrical cords against the wall helps to reduce the risk of tripping and is a safety measure to prevent falls.

Choice C reason: Throw rugs can be a tripping hazard and should be avoided, especially in areas like the bathroom where the floor can be slippery.

Choice D reason: Pot handles should be turned inward, away from the edge of the stove, to prevent accidental spills and burns.

A. "I will suction for less than 15 seconds while inserting the suction catheter." B. "I will set the suction pressure dial between 80 and 120." C. "I will wrap the suction catheters in a clean towel to be used again at a later time." D. "I will suction the mouth before inserting the suction catheter into the tracheostomy."

Correct Answer is A

Explanation

Choice A reason: Suctioning for less than 15 seconds is recommended to minimize the risk of hypoxia and other complications during tracheal suctioning.

Choice B reason: Setting the suction pressure dial between 80 and 120 may be too high and could cause trauma to the tracheal mucosa.

Choice C reason: Wrapping used suction catheters in a clean towel for later use is not recommended due to the risk of infection.

Choice D reason: Suctioning the mouth before the tracheostomy can introduce oral bacteria into the lower airways and should be avoided.

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A nurse has just received the morning change of shift report for four clients. Which of the following clients has the highest priority need?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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