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.

Answer and Explanation

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.

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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.

A. Assess the client's incision every 8 hours for the first 48 hours. B. Inform the assistive personnel of the client's weight-bearing status. C. Instruct the client to cross their legs at the ankles when sitting in a chair. D. Teach the client's partner to assist the client to flex the hip at least 120° each hour.

Correct Answer is B

Explanation

The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.

Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.

Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.

Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.

Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.

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A nurse is caring for four clients. Which of the following assessment findings is the priority?

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