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
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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.
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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