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 C
Explanation
Choice A rationale:
Informing the client of the consequences of decreased cerebral circulation is premature without understanding the client's specific reasons for refusing the surgery. Jumping to consequences might not address the underlying fears or concerns the client has, potentially leading to increased resistance or anxiety.
Choice B rationale:
Initiating a mental health consultation is a valuable step if the client's refusal appears to be influenced by psychological or emotional factors. However, before involving mental health professionals, it's important for the nurse to engage in a direct conversation with the client to explore their thoughts, fears, and reservations.
Choice C rationale:
Discussing the client's concerns about having the surgery is the most appropriate action in this scenario. Engaging in an open and nonjudgmental conversation allows the nurse to understand the client's perspective, provide information, clarify misconceptions, and address any fears or uncertainties. This approach respects the client's autonomy and promotes shared decision-making.
Choice D rationale:
Providing the client with information on additional treatment options might be premature if the client's main concern is related to the current recommended surgery. It's crucial to first address the client's specific reservations before exploring other treatment possibilities.
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.
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.