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 value should be reported to the provider because it indicates an elevated blood urea nitrogen (BUN) level, which can reflect impaired renal function or dehydration. The normal range of BUN is 7 to 20 mg/dL. NSAIDs can cause renal toxicity by reducing blood flow to the kidneys and interfering with their ability to filter waste products.
Choice B reason: This value does not need to be reported to the provider because it indicates a normal hematocrit level, which measures the percentage of red blood cells in the blood volume. The normal range of hematocrit is 38% to 50% for men and 34% to 45% for women.
Choice C reason: This value does not need to be reported to the provider because it indicates a normal total bilirubin level, which measures the amount of bilirubin in the blood that results from the breakdown of red blood cells by the liver. The normal range of total bilirubin is 0.3 to 1.2 mg/dL.
Choice D reason: This value does not need to be reported to the provider because it indicates a normal partial pressure of oxygen (PaO2) level, which measures the amount of oxygen dissolved in the arterial blood. The normal range of PaO2 is 80 to 100 mm Hg.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action because using safety pins to secure the pad in place can puncture or damage the pad and cause leakage or malfunction. The nurse should use Velcro straps or tape to secure the pad in place.
Choice B reason: This is an appropriate action because covering the pad prior to use can prevent direct contact between the pad and the skin and reduce the risk of burns or irritation. The nurse should use a clean towel or sheet to cover the pad.
Choice C reason: This is not an appropriate action because applying the pad for 45 minutes at a time can cause tissue damage or necrosis due to prolonged exposure to heat. The nurse should apply the pad for no more than 20 minutes at a time and check the skin condition frequently.
Choice D reason: This is not an appropriate action because filling the pad with sterile water can increase the cost and waste of resources without any benefit. The nurse should fill the pad with tap water as instructed by the manufacturer.
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