A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

A client who has benign prostate hyperplasia (BPH) and reports dysuria

A client who has ulcerative colitis and reports diarrhea

A client who has emphysema and reports dyspnea

A client who has esophageal cancer and reports painful swallowing

Answer and Explanation

The Correct Answer is C

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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Correct Answer is A

Explanation

Choice A reason: This is the best action, because compression stockings can help improve the blood flow and prevent the formation of new clots in the veins of the legs. Compression stockings can also reduce the swelling, pain, and inflammation caused by thrombophlebitis.

Choice B reason: This is an incorrect action, because cold compresses can cause vasoconstriction and worsen the blood flow and the clotting process in the affected vein. Cold compresses can also increase the discomfort and numbness of the extremity.

Choice C reason: This is an incorrect and dangerous action, because gently massaging the area can dislodge the clot and cause it to travel to the lungs, heart, or brain, resulting in a life-threatening complication, such as pulmonary embolism, myocardial infarction, or stroke.

Choice D reason: This is an incorrect and misleading statement, because heparin is not prescribed to dissolve the thrombus, but to prevent the growth and extension of the existing clot and the formation of new clots. Heparin is an anticoagulant that inhibits the clotting factors in the blood, but does not break down the clot. The body's own enzymes, such as plasmin, are responsible for dissolving the clot.

A. I should take ibuprofen for my joint pain. B. I'm thankful that this type of lupus only affects the skin. C. Each day I should apply a sunblock with a sun protection factor of 15. D. A mild fever is common with SLE and usually does not require medical intervention.

Correct Answer is C

Explanation

Choice A reason: This is an incorrect statement, because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen the renal function and increase the risk of bleeding in clients who have SLE. The client should take acetaminophen or other prescribed medications for joint pain.

Choice B reason: This is an incorrect statement, because SLE is a systemic autoimmune disease that can affect multiple organs and tissues, not just the skin. The client may experience symptoms such as rash, arthritis, nephritis, anemia, or pericarditis.

Choice C reason: This is a correct statement, because sun exposure can trigger or exacerbate the symptoms of SLE. The client should apply a sunblock with a sun protection factor of at least 15 every day, and wear protective clothing and hats when outdoors.

Choice D reason: This is an incorrect statement, because a mild fever can indicate an infection or a flare-up of SLE, which can require medical intervention. The client should monitor the temperature and report any fever or signs of infection to the provider.

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A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has thrombophlebitis. Which of the following actions should the nurse recommend for the plan of care?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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