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: This is the correct answer because limiting fluid intake during meals can prevent early satiety or fullness and allow more room for solid foods that provide calories and nutrients. The nurse should instruct the client to drink fluids between meals rather than with meals.
Choice B reason: This is not a correct instruction because eating lighter, low-calorie foods first can reduce the appetite and energy intake of the client who has COPD and little appetite. The nurse should instruct the client to eat higher-calorie, higher-protein foods first and supplement with snacks or nutritional drinks as needed.
Choice C reason: This is not a correct instruction because consuming three regular meals daily can be difficult or impractical for the client who has COPD and little appetite. The nurse should instruct the client to eat smaller, more frequent meals throughout the day and avoid eating within 1 hour before or after using bronchodilators.
Choice D reason: This is not a correct instruction because eliminating dairy products can deprive the client of calcium, vitamin D, and protein that are essential for bone and muscle health. The nurse should instruct the client to include dairy products in their diet unless they have lactose intolerance or allergy.
Correct Answer is D
Explanation
Choice A reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because difficulty swallowing or dysphagia is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of difficulty swallowing, such as stroke, esophageal disorders, or dementia.
Choice B reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because diarrhea or frequent loose stools is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of diarrhea, such as infection, food intolerance, or medication side effects.
Choice C reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because hyperreflexia or increased reflexes is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of hyperreflexia, such as hyperthyroidism, spinal cord injury, or anxiety.
Choice D reason: This is an expected finding for a client who has a potassium level of 3.2 mEq/L because muscle weakness or decreased muscle strength is a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should monitor the client's vital signs, electrocardiogram (ECG), and serum potassium levels and administer potassium supplements as prescribed.
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