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 D
Explanation
Choice A reason: This is not an appropriate action because positioning the fractured arm below the level of the client's heart can increase swelling, pain, or compartment syndrome in the affected extremity due to impaired venous return and increased pressure within closed spaces. The nurse should position the fractured arm above or at least at level with the client's heart and use a sling or pillow for support.
Choice B reason: This is not an appropriate action because immobilizing the client's fingers using a hand splint can reduce mobility, circulation, or sensation in the affected extremity and increase the risk of contractures, nerve damage, or infection. The nurse should encourage the client to move their fingers and thumb frequently and monitor for any signs of impaired neurovascular status.
Choice C reason: This is not an appropriate action because using a hair dryer to blow hot air into the cast to relieve itching can cause burns, infection, or damage to the skin or cast. The nurse should advise the client to avoid scratching, inserting objects, or applying powders or lotions inside the cast and use cool air, ice packs, or antihistamines as prescribed to relieve itching.
Choice D reason: This is an appropriate action because performing neurovascular checks of the affected extremity every 2 hours can assess the circulation, sensation, and movement of the extremity and detect any signs of impaired neurovascular status, such as pallor, cyanosis, numbness, tingling, or paralysis. The nurse should compare the affected extremity with the unaffected one and report any abnormal findings to the provider.
Correct Answer is D
Explanation
Choice A reason: This is not a therapeutic effect of aprepitant because aprepitant is not an analgesic drug that can relieve pain. Aprepitant is an antiemetic drug that can prevent nausea and vomiting caused by chemotherapy or surgery.
Choice B reason: This is not a therapeutic effect of aprepitant because aprepitant does not affect the balance or vestibular system that can cause dizziness. Aprepitant works by blocking the action of substance P, a neurotransmitter involved in nausea and vomiting.
Choice C reason: This is not a therapeutic effect of aprepitant because aprepitant does not affect the cardiac rhythm or conduction that can cause dysrhythmias. Aprepitant has a low risk of interacting with other drugs that can affect the heart, such as warfarin or digoxin.
Choice D reason: This is a therapeutic effect of aprepitant because aprepitant can prevent nausea and vomiting caused by chemotherapy or surgery by blocking the action of substance P, a neurotransmitter involved in nausea and vomiting. The nurse should monitor the client's oral intake, hydration status, and weight and report any signs of dehydration or malnutrition.
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