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 C
Explanation
Choice A reason: This is not an appropriate action because keeping the lights dimmed can increase the risk of falls, confusion, or agitation in the client who has Alzheimer's disease. The nurse should provide adequate lighting and reduce glare and shadows in the client's room and environment.
Choice B reason: This is not an appropriate action because alternating the client's daily routine can cause stress, anxiety, or frustration in the client who has Alzheimer's disease. The nurse should maintain a consistent and structured routine and schedule for the client and provide cues and reminders as needed.
Choice C reason: This is an appropriate action because participating in reminiscence therapy with the client can enhance their cognitive function, mood, and self-esteem by stimulating their long-term memory and encouraging them to share their past experiences, feelings, and values. The nurse should use photos, music, or objects that are meaningful to the client and listen actively and respectfully.
Choice D reason: This is not an appropriate action because raising the four side rails on the client's bed can be considered a form of restraint that can harm or injure the client who has Alzheimer's disease. The nurse should use alternative measures to ensure the client's safety and comfort, such as lowering the bed, using a bed alarm, or providing frequent supervision.
Correct Answer is ["1000"]
Explanation
To lose 0.9 kg (2 lb) of body fat per week, the client needs to create a weekly caloric deficit of 7,000 calories (3,500 x 2).
This means that the client needs to consume 7,000 calories less than he burns in a week.
To achieve this, the client needs to reduce his daily caloric intake by 1,000 calories (7,000 / 7).
For example, if the client normally consumes 2,500 calories per day, he should reduce it to 1,500 calories per day.
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