A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?
A client who had an appendectomy and has a urine output of 260 mL over 8 hr
A client who is immobile and has had an episode of urinary incontinence
A client who has COPD and an oxygen saturation of 99%
A client who has a concussion and has developed aphasia
The Correct Answer is D
A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.
B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.
C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.
D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Trim off the rough edges of the cast if it bothers you in order to promote comfort.": The rough edges should be addressed by the healthcare provider to prevent injury to the skin, as cutting the cast improperly could cause damage to the structure or harm the client.
B. "You might feel tightness and pain with the cast and that is a normal feeling.": Tightness and pain could indicate complications such as compartment syndrome, which requires immediate attention. The client should report any unusual or severe pain, and tightness.
C. "You might feel itchy under the cast, and it is okay to scratch under the cast with a very slim tool.": Scratching under the cast with any object can cause skin irritation, injury, or infection. Itching can be managed with prescribed methods, but inserting objects into the cast should be avoided.
D. "Once the cast is dry, you can shower if you cover it with a plastic covering.": After the cast is fully dry, the client can protect it from water by covering it with a plastic bag or other waterproof covering during showers to keep it dry and intact.
Correct Answer is A
Explanation
A. Soiled cat litter: Clients with HIV are at increased risk for infections, including toxoplasmosis, which can be contracted from handling soiled cat litter. The nurse should instruct the client to avoid contact with cat litter to prevent exposure to these pathogens.
B. Pasteurized milk: Pasteurized milk is safe to consume and does not pose a significant risk for infection in clients with HIV. The pasteurization process kills harmful bacteria, making it safe for immunocompromised individuals.
C. Scrambled eggs: Scrambled eggs are safe to eat as long as they are properly cooked. The risk of infection from eggs is primarily related to undercooking, which is not specific to HIV-positive clients.
D. Electric razor: An electric razor is safe to use, provided it is kept clean and sanitized. Disposable razors or proper hygiene practices can prevent the risk of cuts and infections, which is not specific to HIV-positive individuals.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.