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 B
Explanation
Choice A reason: This is not a food that the nurse should recommend because oatmeal is high in fiber and phytates, which are compounds that can bind to iron and reduce its absorption in the gastrointestinal tract. The nurse should advise the client to avoid consuming foods high in fiber or phytates within 2 hours before or after taking ferrous sulfate.
Choice B reason: This is a food that the nurse should recommend because raw oranges are high in vitamin C, which is an antioxidant that can enhance iron absorption by reducing it to its more soluble form. The nurse should advise the client to consume foods high in vitamin C, such as citrus fruits, tomatoes, or peppers, along with ferrous sulfate.
Choice C reason: This is not a food that the nurse should recommend because cheese is high in calcium and casein, which are substances that can interfere with iron absorption by forming insoluble complexes with it. The nurse should advise the client to avoid consuming foods high in calcium or casein, such as dairy products, eggs, or soybeans, within 2 hours before or after taking ferrous sulfate.
Choice D reason: This is not a food that the nurse should recommend because baked potatoes are high in starch and oxalates, which are compounds that can inhibit iron absorption by forming insoluble salts with it. The nurse should advise the client to avoid consuming foods high in starch or oxalates, such as potatoes, spinach, or rhubarb, within 2 hours before or after taking ferrous sulfate.
Correct Answer is B
Explanation
Choice A reason: This is not a food that the nurse should recommend because oatmeal is high in fiber and phytates, which are compounds that can bind to iron and reduce its absorption in the gastrointestinal tract. The nurse should advise the client to avoid consuming foods high in fiber or phytates within 2 hours before or after taking ferrous sulfate.
Choice B reason: This is a food that the nurse should recommend because raw oranges are high in vitamin C, which is an antioxidant that can enhance iron absorption by reducing it to its more soluble form. The nurse should advise the client to consume foods high in vitamin C, such as citrus fruits, tomatoes, or peppers, along with ferrous sulfate.
Choice C reason: This is not a food that the nurse should recommend because cheese is high in calcium and casein, which are substances that can interfere with iron absorption by forming insoluble complexes with it. The nurse should advise the client to avoid consuming foods high in calcium or casein, such as dairy products, eggs, or soybeans, within 2 hours before or after taking ferrous sulfate.
Choice D reason: This is not a food that the nurse should recommend because baked potatoes are high in starch and oxalates, which are compounds that can inhibit iron absorption by forming insoluble salts with it. The nurse should advise the client to avoid consuming foods high in starch or oxalates, such as potatoes, spinach, or rhubarb, within 2 hours before or after taking ferrous sulfate.
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