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

Choice A rationale:

Since the client speaks a different language than the nurse, involving an interpreter is crucial to ensure effective communication during the preoperative teaching. This will help the client fully understand the procedure, potential risks, and postoperative care instructions.

Choice B rationale:

A social worker primarily addresses psychosocial needs and resources. While they play an important role, their involvement wouldn't directly address the language barrier during the preoperative teaching.

Choice C rationale:

An occupational therapist assists with physical function and daily activities. While they might be involved postoperatively, their role is not as crucial for overcoming the language barrier during preoperative teaching.

Choice D rationale:

A spiritual advisor provides support based on religious or spiritual beliefs. While emotional and spiritual support are important, their involvement in this scenario doesn't address the language barrier and the need for accurate information during preoperative teaching.

A. Remind the staff members that this is a breach of confidentiality. B. Discuss the issue with the nurse manager. C. Request that an administrative restriction be placed on the client's record access. D. Prepare a memo for the facility ethics committee.

Correct Answer is A

Explanation

Choice A rationale:

Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.

Choice B rationale:

Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.

Choice C rationale:

Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.

Choice D rationale:

Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.

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

Nursing Test Bank

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