A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

A client who needs their daily weight taken with a bed scale

A client who has a leg ulcer and needs their dressing changed

A client who has an indwelling urinary catheter bag that needs to be emptied

A client who has dysphagia and has a scheduled feeding

Answer and Explanation

The Correct Answer is D

A. A client who needs their daily weight taken with a bed scale: Daily weight is important for monitoring fluid status, but it is not immediately life-threatening if delayed. This task can be completed after more urgent client needs are addressed.

B. A client who has a leg ulcer and needs their dressing changed: Dressing changes are important for preventing infection and promoting healing, but this intervention is not urgent compared to risks involving airway or nutrition.

C. A client who has an indwelling urinary catheter bag that needs to be emptied: Emptying a catheter bag helps with comfort and infection control but does not represent a priority safety concern. It can safely wait until more urgent tasks are completed.

D. A client who has dysphagia and has a scheduled feeding: Dysphagia places the client at high risk for aspiration during feeding, which can compromise the airway and lead to respiratory complications. This client requires the nurse’s immediate attention to ensure safe feeding.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Safety: The client has an unsteady gait, dizziness on standing, ecchymosis in multiple healing stages, and abrasions, all of which raise concerns for recurrent falls or possible neglect. Ensuring the client’s immediate safety is the top priority before addressing other needs.
Notify Adult Protective Services: Scattered ecchymoses in different healing stages, poor hygiene, and possible neglect warrant a report to APS for further investigation to ensure the client’s protection.

Rationale for incorrect choices:

Hygiene: While poor hygiene, lice infestation, and odor are evident, these concerns are not immediately life-threatening compared to the safety risks of falls and potential abuse or neglect. They can be addressed after the client is safe and protected.
Nutrition: No clear evidence of malnutrition is provided, though decreased skin turgor suggests possible dehydration. However, nutrition needs are a lower priority than immediate safety concerns related to falls and potential abuse.
Arrange for dietary consult: This intervention would be appropriate later for long-term care planning, but it does not address the client’s most urgent risk factors.
Consult with social services for support: Social services may help coordinate resources, but urgent reporting to APS is needed first because of suspected neglect and abuse indicators.

A. Schedule the client as the last surgery of the day. B. Notify ancillary departments of the client's allergy. C. Label the surgical suite as latex-free. D. Provide powdered gloves for the staff's use. E. Ensure a latex allergy cart is available.

Correct Answer is ["B","C","E"]

Explanation

A. Schedule the client as the last surgery of the day: Clients with latex allergy should ideally be scheduled as the first surgery of the day to minimize exposure to latex particles that may accumulate in the air and environment. Scheduling last increases exposure risk.

B. Notify ancillary departments of the client's allergy: Informing all relevant departments, such as pharmacy, radiology, and laboratory services, ensures that latex-free supplies are used consistently throughout the client’s care. This prevents accidental exposure to latex-containing products.

C. Label the surgical suite as latex-free: Clearly labeling the operating room reduces the risk of staff inadvertently bringing in latex products. It promotes team-wide awareness and helps maintain a safe surgical environment for the client.

D. Provide powdered gloves for the staff's use: Powdered latex gloves are contraindicated because they release latex proteins into the air, which increases the risk of allergic reactions. Only non-latex, powder-free gloves should be provided.

E. Ensure a latex allergy cart is available: Having a latex allergy cart stocked with latex-free supplies ensures that all necessary items are available during the procedure. This reduces delays and eliminates the need to search for suitable equipment during surgery.

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A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client being admitted into a long-term care facility. Exhibits Complete the following sentence by using the list of options. The nurse should address the client's dropdownfollowed bydropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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