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 B
Explanation
The answer isb. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”
a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor.The AP should know the client’s name and room number for identification and safety purposes.
c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage.The nurse should provide clear and measurable criteria for the AP to follow.
d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant.The nurse should provide specific and individualized instructions for each client
Correct Answer is B
Explanation
The correct answer is choice B: "Ask the client to explain the procedure that is being performed."
Choice A rationale:
While verifying that the client understands the risks of the surgery (Choice A) is important, the question specifically asks about verifying informed consent. Informed consent involves ensuring that the patient comprehends the procedure being performed, its benefits, risks, and alternatives. While understanding the risks is a part of this, it's not the complete picture.
Choice B rationale:
The correct response is "Ask the client to explain the procedure that is being performed." This approach ensures that the client truly comprehends the procedure and its implications. If the client can accurately explain the procedure, it indicates a better understanding of what they are consenting to, which aligns with the concept of informed consent.
Choice C rationale:
Answering the client's questions about the outcomes of the surgery (Choice C) is important for providing education and addressing concerns, but it doesn't directly verify informed consent. The focus of informed consent is on the procedure itself, including its nature, purpose, and potential risks.
Choice D rationale:
Determining if the client understands the benefits of the procedure (Choice D) is only part of the informed consent process. While understanding the benefits is essential, it's equally important to ensure the client comprehends the risks and alternatives, which is better assessed by having the client explain the procedure.
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.