A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A client who has dementia and is experiencing paranoia

A client who has a UTI and reports itching after receiving a dose of cefaclor PO

A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr

A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Answer and Explanation

The Correct Answer is B

A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.

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Correct Answer is B

Explanation

A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.

A. Raisin toast B. Soft-serve ice cream C. String cheese D. Hot tea

Correct Answer is A

Explanation

A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.

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A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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