A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?
A client who had abdominal surgery 2 days ago and the incision line is separating
A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10
A client who has a chronic tracheostomy and is intermittently coughing up clear sputum
A client who has Clostridium difficile and has liquid stools
The Correct Answer is A
Choice A reason: This is the correct answer because a client who had abdominal surgery 2 days ago and the incision line is separating has a potential complication of wound dehiscence or separation of the surgical incision that can lead to evisceration or protrusion of the internal organs. This is a medical emergency that requires immediate intervention and notification of the provider.
Choice B reason: This is not a priority client to attend to because a client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 has a stable condition that can be managed with analgesics, ice packs, or elevation as prescribed. The nurse should assess the client's pain level, location, and quality and provide comfort measures as needed.
Choice C reason: This is not a priority client to attend to because a client who has a chronic tracheostomy and is intermittently coughing up clear sputum has an expected finding that indicates normal secretion clearance and respiratory function. The nurse should monitor the client's oxygen saturation, respiratory rate, and breath sounds and provide tracheostomy care as prescribed.
Choice D reason: This is not a priority client to attend to because a client who has Clostridium difficile and has liquid stools has an expected finding that indicates infection of the colon by bacteria that produce toxins that cause inflammation, diarrhea, and abdominal pain. The nurse should implement contact precautions, collect stool samples for testing, and administer antibiotics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Allowing space for one finger to be placed under the tube ties is a correct action for tracheostomy care. This ensures that the tube ties are not too tight, which can cause skin breakdown, pressure necrosis, or impaired circulation. The tube ties should also not be too loose, which can cause accidental dislodgement of the tube.
Choice B reason: Applying suction pressure while inserting the catheter into the trachea is an incorrect action for tracheostomy care. This can cause trauma to the tracheal mucosa and increase the risk of infection and bleeding. The nurse should apply suction pressure only while withdrawing the catheter and rotate it gently to remove secretions.
Choice C reason: Suctioning the client for 20 seconds with each pass is an incorrect action for tracheostomy care. This can cause hypoxia, bradycardia, or cardiac arrest due to vagal stimulation. The nurse should suction the client for no more than 10 to 15 seconds with each pass and allow at least 30 seconds between passes for oxygenation.
Choice D reason: Cleansing around the stoma with povidone-iodine is an incorrect action for tracheostomy care. Povidone-iodine is a strong antiseptic that can irritate the skin and cause allergic reactions. The nurse should cleanse around the stoma with normal saline or sterile water and apply a thin layer of water-soluble lubricant to protect the skin.
Correct Answer is A
Explanation
Choice A reason: This is an indication that the client needs further testing because a palpable area of induration, greater than 10 mm (0.4 in) in diameter, is considered a positive result for the tuberculin skin test, which means that the client has been exposed to Mycobacterium tuberculosis and may have latent or active tuberculosis infection. The nurse should refer the client for chest x-ray and sputum culture and sensitivity tests to confirm the diagnosis and rule out other conditions.
Choice B reason: This is not an indication that the client needs further testing because an area of ecchymosis, greater than 12 mm (0.5 in) in diameter, is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and monitor the site for any signs of infection or inflammation.
Choice C reason: This is not an indication that the client needs further testing because tenderness at the injection site is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and provide comfort measures as needed.
Choice D reason: This is not an indication that the client needs further testing because a nonpalpable area of redness, less than 5 mm (0.2 in) in diameter, is considered a negative result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and educate the client about tuberculosis prevention and screening recommendations.
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