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A nurse in a medical-surgical unit is caring for 6 clients.

Exhibits

Complete the following sentence by using the lists of options.

The first client the nurse should assess is

followed  by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

    1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
    2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
    3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

    1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
    2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
    3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

  1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
    2.  Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
    3.  Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
    4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
    5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
    6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)


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Related Questions

Correct Answer is C

Explanation

A. Flush the client's tube with 5 mL of water. – This is incorrect because the standard amount of water used to flush a feeding tube is typically 30–50 mL to maintain patency and prevent clogging.
B. Place the client in a supine position. – This is incorrect because the client should be placed in a semi-Fowler’s or Fowler’s position (at least 30–45 degrees) to reduce the risk of aspiration.
C. Check the pH level of the client's gastric contents. – This is the correct answer. Checking the pH of gastric contents (typically ≤5.5) helps confirm proper tube placement before administering feedings, reducing the risk of aspiration.
D. Check the patency of the client's tube every 8 hr. – This is incorrect because tube patency should be checked before each feeding or medication administration, not just every 8 hours.

Correct Answer is C

Explanation

A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.

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