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 A

Explanation

A. Hepatitis C is a contraindication to atorvastatin due to the potential for hepatotoxicity and worsening liver function in individuals with preexisting liver disease.

B. Crohn's disease, peptic ulcer disease, and bronchitis are not contraindications to atorvastatin.

However, caution may be needed in individuals with gastrointestinal conditions due to potential gastrointestinal side effects of the medication.

C. Peptic ulcer disease is not a contraindication to atorvastatin. However, caution may be warranted in individuals with a history of gastrointestinal bleeding or ulcers due to potential gastrointestinal side effects of the medication.

D. Bronchitis is not a contraindication to atorvastatin. Atorvastatin primarily affects cholesterol levels and does not directly interact with bronchitis, a respiratory condition.

A. Perform active range-of-motion exercises. B. Maintain the head at a midline position. C. Suction the airway frequently. D. Perform neurological checks every 4 hours.

Correct Answer is B

Explanation

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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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

A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

Correct Answer is A

Explanation

A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

Correct Answer is B

Explanation

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