A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to assess first?
A client who has epidural analgesia and weakness in the lower extremities.
A client who has diabetes mellitus and an HbA1c of 6.89%.
A client who has a hip fracture and a new onset of tachypnea.
A client who has sinus arrhythmia and is receiving cardiac monitoring.
The Correct Answer is C
Choice A rationale:
The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.
Choice B rationale:
The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.
Choice C rationale:
The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.
Choice D rationale:
The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Identifying possible precipitating factors related to the infections is the first step in addressing the issue of increased catheter infections. Understanding the potential causes, such as poor catheter insertion techniques, inadequate hygiene practices, or contaminated equipment, can help the nurse pinpoint the areas that need improvement. By identifying these factors, the nurse can implement targeted interventions to prevent future infections.
Choice B rationale:
Meeting with providers to discuss measures to decrease infections is a valid step, but it should come after identifying the specific factors contributing to the infections. Without a clear understanding of the root causes, the discussion with providers may lack focus and may not lead to effective solutions.
Choice C rationale:
Revising the current policy for catheter care can be considered after identifying the precipitating factors. Policy revision should be based on evidence-based practices and a thorough understanding of the issues contributing to the infections. Simply revising the policy without addressing the underlying causes may not lead to significant improvements.
Choice D rationale:
Scheduling nursing staff training for infection control procedures is an important step in preventing infections, but it should also follow the identification of specific issues related to the catheter infections. Training programs can be tailored to address the identified problems and provide targeted education to the staff members involved.
Correct Answer is ["A","E","G","H"]
Explanation
Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.
Choice F rationale:
Hypertension, or high blood pressure, is not a direct risk for this client based on the information provided. While chronic diseases like multiple sclerosis can indirectly contribute to hypertension through stress or medication side effects, it’s not directly caused by immobility or multiple sclerosis.
Choice G rationale:
Pressure injury is a significant risk for this client due to their constant positioning on one side and refusal to change positions. Pressure injuries occur when there is prolonged pressure on one area of the body, restricting blood flow and leading to tissue damage and necrosis.
Choice H rationale:
Atelectasis, or collapse of part of the lung, is also a risk for this client due to their immobility. When a person is immobile, they may take shallow breaths which do not fully inflate the lungs, leading to areas of collapse.
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