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 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.
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate intervention because checking for increased salivation is not relevant for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should check for decreased salivation or dry mouth, which is a common symptom of botulism poisoning.
Choice B reason: This is not an appropriate intervention because administering clindamycin hydrochloride is not effective for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should administer botulism antitoxin as prescribed to neutralize the toxin and prevent further damage.
Choice C reason: This is not an appropriate intervention because placing in contact isolation is not necessary for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should use standard precautions and dispose of any contaminated food properly.
Choice D reason: This is an appropriate intervention because monitoring for muscle paralysis is essential for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should assess the client's muscle strength, reflexes, and respiratory function and provide supportive care as needed.
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