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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.
Reasons why the other options are not answers:
Option A: Having an assistive personnel feed the client may decrease the client's autonomy.
Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.
Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.
Correct Answer is C
Explanation
The correct answer is choice C. Place white tape on the edges of stairs.
Choice A rationale:
While having the furnace inspected is important for safety, it should be done annually, not every two years.Regular inspections help prevent carbon monoxide leaks and ensure the furnace is functioning properly.
Choice B rationale:
Running wires and cords under carpeting is a safety hazard. It can lead to overheating and potentially cause a fire.Additionally, it creates a tripping hazard.
Choice C rationale:
Placing white tape on the edges of stairs is a recommended safety measure.It increases visibility, especially for older adults who may have vision impairments, reducing the risk of falls.
Choice D rationale:
Placing area rugs on wooden floors can be dangerous as they can slip and cause falls.If area rugs are used, they should be secured with non-slip backing or tape.
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