A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who told an assistive personnel he is short of breath

A client who has a prescription for discharge

A client who received oral pain medication 30 minutes ago

A client who is scheduled for an abdominal x-ray and is awaiting transport

Answer and Explanation

The Correct Answer is A

Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.

Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.

Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.

Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.

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Correct Answer is D

Explanation

Choice A reason: Cleaning with an alcohol-based solution is not recommended as it can be irritating and does not prevent infection.
Choice B reason: Routine irrigation of the catheter is not recommended as it can introduce infection.
Choice C reason: Replacing the catheter routinely every three days is not recommended and can increase the risk of infection.
Choice D reason: Ensuring the catheter tubing is free of kinks, twisting, and dependent loops is important to maintain urine ﬂow and prevent infection.

A. Ask whether the patient has any questions about the procedure. B. Ask the patient to void before the procedure. C. Check for an allergy to iodine or shellfish. D. Assess the client's ability to remain still for the procedure.

Correct Answer is C

Explanation

Choice A reason: While it is important to address any questions the patient may have, it is not the highest priority before an IVP procedure.

Choice B reason: Asking the patient to void before the procedure is a standard practice, but it is not the highest priority. The bladder should be empty to allow for clear imaging, but this can be managed at the time of the procedure.

Choice C reason: Checking for an allergy to iodine or shellfish is the highest priority because the contrast medium used in an IVP can cause severe allergic reactions in patients with these allergies. This assessment must be done before administering the contrast to prevent potentially life-threatening complications.

Choice D reason: Assessing the client's ability to remain still is important for the quality of the images, but it is not as critical as ensuring the safety of the patient regarding potential allergic reactions.

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A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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