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 has Clostridium difficile and has liquid stools

A client who had abdominal surgery 2 days ago and the incision line is separating

A client who has a chronic tracheostomy and is intermittently coughing up clear sputum

A client who fell 12 hr ago and reports pain as 4 on a scale of 0 to 10

Answer and Explanation

The Correct Answer is B

The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.

Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.

Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.

Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should instruct the client to avoid taking medications for erectile dysfunction, such as sildenafil, within 24 hours of taking nitroglycerin due to the risk of severe hypotension.

Reasons why the other options are not answers:

Option B: Metformin is not contraindicated with nitroglycerin.

Option C: Omeprazole is not contraindicated with nitroglycerin.

Option D: Atorvastatin is not contraindicated with nitroglycerin.

A. Apply moist heat to the incision while in bed. B. Sit in a straight-backed chair. C. Perform range of motion exercises by adducting the hip.

Correct Answer is B

Explanation

Sit in a straight-backed chair. After a total hiparthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The clientshould apply ice to the incision site, not moist heat, in the first few dayspostoperatively. The client should avoid adducting the hip as this can also riskdislocation of the new hip joint. Hydrogen peroxide should not be used to cleanthe surgical incision, as it can delay wound healing.

Choice A: The client shouldapply ice to the incision site, not moist heat, in the first few days postoperatively.

Choice C: The client should avoid adducting the hip as this can risk dislocation ofthe new hip joint.

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A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is 24 hours postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. What action should the nurse take?

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?

A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?