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 D
Explanation
"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heartdisease.
Choice B is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.
Choice C is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.
An explanation for why the other choices are not answers: A – Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement. B – Lowering, not raising, LDL cholesterol is essential in preventing heart disease, so this is not the correct statement. C – Exercising only twice a week for 25 minutes is not enough to prevent heart disease. Thus, this is not the correct statement.
Correct Answer is ["D","E"]
Explanation
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.
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