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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Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

A. "Consume 500 fewer calories per day than your estimated calorie needs." B. "Plan your meals so up to 40 percent of your calories come from fats." B. "Include refined grains as a good carbohydrate in your diet." C. "Reward yourself with special foods for achieving short-term goals."

Correct Answer is A

Explanation

"Consume 500 fewer calories per day than your estimated calorie needs." Consuming slightly fewer calories than one's estimated calorie needs can help promote weight loss in a healthy and safe way. Planningmeals so that up to 40% of calories come from fats is not typically recommendedwhen trying to lose weight, as too much fat can lead to excess calorie intake. Refined grains should be avoided in favor of whole grains, and it is not recommended to reward oneself with special foods for achieving short-termgoals.

Choice B: Planning meals so that up to 40% of calories come from fat is nottypically recommended when trying to lose weight, as too much fat can lead toexcess calorie intake.

Choice C: Refined grains should be avoided in favor of wholegrains.

Choice D: It is not recommended to reward oneself with special foods forachieving short-term goals.

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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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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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