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 D
Explanation
A. Restricting dietary calcium intake is not typically recommended for preventing nephrolithiasis; in fact, adequate calcium intake may decrease the risk of kidney stone formation.
B. Limiting fluid intake is not recommended for individuals with nephrolithiasis; adequate fluid intake helps prevent kidney stone formation.
C. Complex carbohydrates do not significantly impact the risk of nephrolithiasis; dietary changes should focus on other factors such as oxalate intake.
D. Foods high in oxalates, such as spinach, beets, nuts, and chocolate, can contribute to the formation of kidney stones in susceptible individuals, so it's important to avoid them.
Correct Answer is C
Explanation
A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.
B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.
C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care
activities.
D. Advise the client to leave the television in the room on when trying to fall asleep - Screen
time before bed can interfere with falling asleep due to the stimulating effect of light and content.
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