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
Choice A rationale:
Determining the swallowing ability of a client who has had a stroke requires clinical judgment and assessment skills that fall within the scope of a registered nurse's practice. This task involves assessing potential risks and complications related to the client's condition.
Choice B rationale:
Providing an enteral feeding to a client who has Crohn's disease is within the scope of an LPN's practice. LPNs are trained to administer enteral feedings and manage stable clients with chronic conditions, such as Crohn's disease, under the supervision of a registered nurse.
Choice C rationale:
Developing a teaching plan for a client with a new diagnosis of type 2 diabetes mellitus involves comprehensive assessment, education, and planning. This task requires the expertise of a registered nurse, as it encompasses various aspects of disease management and requires tailored education based on individual client needs.
Choice D rationale:
Weighing a client who is 3 days postoperative following coronary artery bypass grafting involves monitoring for postoperative complications and assessing the client's stability. This task requires clinical judgment and the ability to recognize potential issues, making it more appropriate for a registered nurse to perform.
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.
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