A nurse is caring for four clients. Which of the following assessment findings is the priority?
A client who has facial drooping following a stroke 8 hours ago.
A client who has a femur fracture and reports feeling short of breath.
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.
The Correct Answer is B
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.
Choice A rationale:
The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.
Choice B rationale:
Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.
Choice C rationale:
The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.
Choice D rationale:
The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.
Correct Answer is B
Explanation
Choice A rationale:
Showing the AP how to remove an indwelling urinary catheter may not provide sufficient evidence of their competency to perform the task safely and effectively. This approach assumes that observation alone is enough to determine competence, which is not necessarily the case. It's important to have a more structured assessment of the AP's skills.
Choice B rationale:
Reviewing the AP's skill competency checklist is the most appropriate action to ensure the AP is qualified to remove the indwelling urinary catheter. Competency checklists outline specific skills and steps required for a task, and they serve as a standardized way to assess the AP's capabilities. This process ensures that the AP has received proper training and has demonstrated competence before performing the procedure independently.
Choice C rationale:
Simply asking the AP if they know how to remove an indwelling urinary catheter is not a comprehensive method for verifying their qualifications. Self-assessment can be unreliable and may not accurately reflect the AP's actual skill level. Relying solely on self-reporting could compromise patient safety and quality of care.
Choice D rationale:
Pairing the newly hired AP with an experienced AP might provide some guidance, but it doesn't systematically assess the individual's competence. The level of experience of the experienced AP may vary, and their ability to teach or evaluate the new AP's skills may not be standardized.
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