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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is choice C. Asthma.

Choice A rationale:

Glaucoma is not a contraindication for propranolol. Beta-blockers like propranolol can actually be used to manage glaucoma by reducing intraocular pressure.

Choice B rationale:

Irritable bowel syndrome (IBS) is not a contraindication for propranolol. There is no direct interaction between propranolol and IBS that would prevent its use.

Choice C rationale:

Asthma is a contraindication for propranolol. Propranolol is a non-selective beta-blocker, which means it can block beta-2 receptors in the lungs, leading to bronchoconstriction and potentially severe asthma exacerbations.

Choice D rationale:

Migraine headaches are not a contraindication for propranolol. In fact, propranolol is often prescribed as a preventive treatment for migraines.

A. Participate in reminiscence therapy with the client. B. Raise the four side rails on the client's bed. C. Alternate the client's daily routine. D. Keep the lights dimmed.

Correct Answer is A

Explanation

The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.

Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

Correct Answer is C

Explanation

A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?

A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has anemia and has a prescription for ferrous sulfate. Which of the following foods should the nurse recommend that the client consume to increase the absorption of this medication?