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 correct answer is choice A. Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions. Choice B is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is incorrect because gloves should not be reused. Choice D is incorrect because the client should not leave the room while on contact precautions. Choice B is not correct because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is not correct because gloves should not be reused. Choice D is not correct because the client should not leave the room while on contact precautions.

A. Perform suctioning. B. Instill saline into the tubing. C. Check the cuff pressure. D. Increase the humidification.

Correct Answer is A

Explanation

The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.

Other choices:

Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.

Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.

Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.

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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

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Explanation

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