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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.

B. A child who has a compound fracture of the femur and is crying in pain: While painful, a

femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.

C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:

These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.

D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.

A. The client is taking an antidepressant. B. The client has a history of a seizure disorder. C. The client takes aspirin daily. D. The client has a history of rheumatoid arthritis

Correct Answer is C

Explanation

- A: Garlic supplements are not contraindicated for clients taking antidepressants. While garlic is known to have a variety of health benefits, there is no well-documented interaction between garlic supplements and antidepressants that would contraindicate their concurrent use.
- B: There is no direct contraindication for the use of garlic supplements in clients with a history of seizure disorders. Garlic supplements do not have a seizure threshold-lowering effect, which is a common concern with some medications and conditions that may exacerbate seizure disorders.
- C: Garlic supplements may increase the risk of bleeding, especially when taken with other substances that have anticoagulant properties, such as aspirin. This is due to garlic's potential effect on platelet aggregation and the blood clotting process, making it a contraindication for clients who take aspirin daily.
- D: Garlic supplements do not have a contraindication for clients with a history of rheumatoid arthritis. In fact, some studies suggest that garlic may have anti-inflammatory properties, which could be beneficial for individuals with inflammatory conditions like rheumatoid arthritis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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