A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube

A preschooler awaiting discharge instructions prior to leaving the hospital

A toddler who has a respiratory rate of 54/min

A school-age child who reports nausea following chemotherapy

Answer and Explanation

The Correct Answer is C

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

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Correct Answer is C

Explanation

A) Metabolic alkalosis: Metabolic alkalosis is characterized by a high pH and elevated bicarbonate (HCO3). In this scenario, the pH is elevated at 7.6, which supports alkalosis, but the HCO3 level is normal at 24 mEq/L. The PaCO2 is slightly low, which is not typical for metabolic alkalosis, as it would usually show an elevated HCO3 with a compensatory respiratory alkalosis.

B) Respiratory acidosis: Respiratory acidosis would present with a low pH and an elevated PaCO2. In this case, the pH is high at 7.6, indicating alkalosis, and the PaCO2 is also low at 30 mm Hg, which is inconsistent with respiratory acidosis.

C) Respiratory alkalosis: Respiratory alkalosis is indicated by a high pH with a low PaCO2. Here, the pH is elevated at 7.6, and the PaCO2 is decreased at 30 mm Hg, which fits the profile of respiratory alkalosis. The normal HCO3 level suggests that the bicarbonate is not compensating, supporting a primary respiratory alkalosis.

D) Metabolic acidosis: Metabolic acidosis is characterized by a low pH and a low HCO3. In this scenario, the pH is elevated at 7.6, and the HCO3 level is normal at 24 mEq/L, which does not align with metabolic acidosis. The PaCO2 is also low, which is not typical for metabolic acidosis, as it would usually have a normal or high PaCO2.

A. Multiple clots in the client's urinary bag B. Client reports bladder spasms when repositioning in bed C. Obstruction in client's urinary catheter continues after manual irrigation D. Client reports a pain rating of 3 on a 0 to 10 scale

Correct Answer is C

Explanation

A) Multiple clots in the client's urinary bag:
Multiple clots in the urinary bag can be expected after a transurethral resection of the prostate (TURP) as part of the normal postoperative bleeding. While clots can cause concern if they become excessive or obstructive, they are not as immediately critical as a persistent obstruction.

B) Client reports bladder spasms when repositioning in bed:
Bladder spasms are a common postoperative symptom following TURP and can be managed with antispasmodic medications and proper catheter care. Although uncomfortable, bladder spasms do not pose an immediate threat to the client’s health.

C) Obstruction in client's urinary catheter continues after manual irrigation:
A persistent obstruction in the urinary catheter after manual irrigation is a significant concern. This can indicate a severe blockage that might prevent urine from draining, leading to bladder distention, potential damage to the surgical site, and increased risk of infection. Immediate intervention is required to resolve the obstruction and ensure proper urinary drainage.

D) Client reports a pain rating of 3 on a 0 to 10 scale:
A pain rating of 3 on a 0 to 10 scale indicates mild pain, which is common in the postoperative period and can be managed with analgesics. While pain management is important, this level of pain does not constitute an urgent issue requiring immediate reporting to the provider.

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A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

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Correct Answer is C

Explanation

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