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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action for this client because placing them in a negative airflow room is indicated for clients who have airborne infections, such as tuberculosis or measles, that can spread through small particles that remain suspended in air. Streptococcal pharyngitis, also known as strep throat, is caused by bacteria that spread through large respiratory droplets that fall within 3 feet from source.
Choice B reason: This is an appropriate action for this client because implementing droplet precautions can prevent transmission of streptococcal pharyngitis to others by contact with respiratory secretions or contaminated objects. The nurse should wear a surgical mask when entering the client's room and instruct visitors to do so as well. The nurse should also place a mask on the client when transporting them outside their room.
Choice C reason: This is not an appropriate action for this client because placing them on a fluid restriction can cause dehydration and impair mucosal healing. The nurse should encourage the client to drink plenty of fluids, such as water, tea, or broth, to soothe the throat and prevent dryness.
Choice D reason: This is not an appropriate action for this client because obtaining a throat culture after the initial dose of antibiotics can affect the accuracy of the test results and delay diagnosis and treatment. The nurse should obtain a throat culture before starting antibiotics to confirm the presence of streptococcal bacteria and guide antibiotic therapy.
Correct Answer is D
Explanation
Choice A reason: This is not an immunization that the nurse should identify as needed for this client because measles, mumps, and rubella are viral diseases that can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice B reason: This is not an immunization that the nurse should identify as needed for this client because human papilloma virus is a sexually transmitted infection that can cause genital warts or cervical cancer and can be prevented by vaccination before sexual activity or exposure. The nurse should educate the client about safe sex practices and screening tests for cervical cancer.
Choice C reason: This is not an immunization that the nurse should identify as needed for this client because inactivated polio virus is a vaccine that protects against poliomyelitis, a viral disease that can cause paralysis or death and can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice D reason: This is an immunization that the nurse should identify as needed for this client because herpes zoster is a viral disease that causes shingles, a painful rash with blisters that can affect any part of the body and can be prevented by vaccination in older adults. The nurse should recommend that the client receive two doses of herpes zoster vaccine at least 2 months apart.
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