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.
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Related Questions
Correct Answer is D
Explanation
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.
Correct Answer is D
Explanation
knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
An explanation for incorrect choices:
A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg position
is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone position is lying face down, which is not suitable for sigmoidoscopy.
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