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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Keeping an abduction pillow between the client's legs is a preventive measure to avoid dislocation of the hip prosthesis. This positioning helps maintain the correct alignment of the hip joint, reducing the risk of dislocation. Abduction pillows are commonly used postoperatively after total hip arthroplasty to support proper hip positioning while the patient is in bed.

Choice B rationale:

Elevating the client's affected leg on a pillow when in bed is not recommended after total hip arthroplasty. This position could lead to hip adduction, increasing the risk of prosthesis dislocation. Maintaining abduction (spreading the legs apart) is the key to preventing dislocation, and elevation should be avoided to maintain proper alignment.

Choice C rationale:

Positioning the client's knees slightly higher than the hips when up in a chair is not an appropriate preventive measure for prosthesis dislocation. Proper alignment is crucial, and the client should avoid sitting in low chairs or on low surfaces that could cause the hips to be lower than the knees, potentially leading to dislocation.

Choice D rationale:

Raising the head of the client's bed to a high-Fowler's position is unrelated to preventing prosthesis dislocation. Fowler's position refers to elevating the head of the bed to assist with breathing and facilitate patient comfort. While this position might be suitable for certain respiratory conditions, it has no direct impact on the stability of a hip prosthesis.

A. An angiocatheter. B. A 25-gauge needle. C. A butterfly needle. D. A noncoring needle.

Correct Answer is D

Explanation

Choice A rationale:

An angiocatheter is not appropriate for accessing an implanted venous access port. Angiocatheters are large-bore catheters designed for rapid fluid administration and are typically used for peripheral venous access. They are not suitable for accessing the small, specialized ports used for central venous access.

Choice B rationale:

A 25-gauge needle is too small for accessing an implanted venous access port. While smaller gauge needles are suitable for delicate procedures and patients with fragile veins, they might not provide adequate flow for certain therapies or blood draws. Accessing a port with a needle that is too small can lead to increased pressure, potentially damaging the port or causing discomfort to the patient.

Choice C rationale:

A butterfly needle is also not the best choice for accessing an implanted venous access port. Butterfly needles, also known as winged infusion sets, are commonly used for short-term peripheral venous access. They are not designed for accessing implanted ports, which require a noncoring needle for precise and safe access without damaging the port membrane.

Choice D rationale:

(Correct Choice) A noncoring needle, also known as a Huber needle, is the correct choice for accessing an implanted venous access port. Noncoring needles have a specially designed tip that creates a smaller puncture hole, reducing damage to the port membrane and minimizing patient discomfort. They are specifically designed for accessing ports and are the standard choice for this procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following total hip arthroplasty.Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct Answer is A

Explanation

A nurse is caring for a client who has an implanted venous access port.Which of the following should the nurse use to access the port?

Correct Answer is D

Explanation

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