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 B

Explanation

The correct answer is choice B.

Choice A rationale:

The client does not have transportation for discharge home. Rationale: While transportation is important for discharge planning, it is not the priority concern in this situation. The client's immediate needs and well-being take precedence over transportation concerns.

Choice B rationale:

The client refuses to attend physical therapy sessions. Rationale: The correct choice. After a hip surgery, physical therapy is crucial for preventing complications, promoting mobility, and ensuring optimal recovery. The refusal to attend these sessions could lead to delayed healing, increased risk of complications, and impaired functional outcomes. Addressing the client's resistance to therapy is a priority to ensure the best possible recovery.

Choice C rationale:

The client's home health nurse has not completed the home assessment. Rationale: While a home assessment is important for discharge planning, it is not the most immediate concern. The client's refusal to attend physical therapy could have more immediate and significant effects on their recovery and well-being.

Choice D rationale:

The client describes feelings of depression after family visits. Rationale: While addressing the client's emotional well-being is important, it is not the priority concern in this situation. The refusal to attend physical therapy sessions could have physical consequences that take precedence over the emotional aspect.

A. The nurse places the sterile package with the top flap opening away from the body. B. The nurse pinches the flap on the inside of the package first to open it. C. The nurse reaches over the package to open the left flap. D. The nurse pulls the last flap of the package away from the body.

Correct Answer is A

Explanation

Choice A rationale:

Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.

Choice B rationale:

Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.

Choice C rationale:

Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.

Choice D rationale:

Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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