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 B
Explanation
A. Herpes simplex virus (HSV) type 1 infection is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
B. Hepatitis A is a reportable infectious disease to the CDC due to its potential for public health significance, particularly in outbreaks or clusters of cases.
C. Human papillomavirus (HPV) infection is not typically a reportable diagnosis to the CDC unless it is part of a larger study or surveillance effort.
D. Pediculosis capitis (head lice infestation) is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
Correct Answer is D
Explanation
A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.
B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.
C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.
D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.
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