A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first?
A client who is 3 hr post Foley catheter removal and has not voided
A client who is 3 days postoperative colectomy with a large, loose melena stool
A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10
A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
The Correct Answer is D
A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.
B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.
C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Art therapist: Art therapy can provide a nonverbal outlet for expressing feelings and emotions, which can be particularly beneficial for clients with schizophrenia who may struggle with verbal communication.
B. Speech-language pathologist: While speech-language pathologists may assist with communication difficulties, their expertise is more focused on speech and language disorders rather than addressing emotional expression in clients with schizophrenia.
C. Social worker: Social workers provide support and assistance with various psychosocial
issues, but they may not specifically address the client's difficulty expressing feelings through therapeutic interventions like art therapy.
D. Recreational therapist: Recreational therapy focuses on promoting leisure and recreational
activities to improve overall well-being, but it may not directly address the client's difficulty with emotional expression.
Correct Answer is C
Explanation
A. "Limit your meals to three times per day." - Incorrect. Following gastric bypass surgery,
clients are typically advised to eat small, frequent meals rather than limiting to three large meals per day.
B. "Consume at least 25 grams of fiber daily." - Incorrect. While fiber is important for gastrointestinal health, clients following gastric bypass surgery may need to avoid high-fiber foods initially and gradually reintroduce them based on individual tolerance.
C. "Start each meal with a protein source." - Correct. Protein is essential for wound healing and maintenance of muscle mass after gastric bypass surgery. Starting each meal with a protein source helps ensure an adequate intake.
D. "Check your blood glucose level before each meal." - This instruction is not directly related to dietary management following gastric bypass surgery. Blood glucose monitoring may be necessary for clients with diabetes, but it is not specific to post-gastric bypass dietary
instructions.
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