A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who has cirrhosis and severe pruritus
A client who has a femur fracture and reports numbness of the toes
A client who had a renal biopsy 3 hr ago and has pink-tinged urine
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
The Correct Answer is B
Numbness of the toes following a femur fracture can indicate potential nerve compromise or damage, which requires immediate attention. Nerve compression or injury can lead to long-term complications if not addressed promptly. It is important for the nurse to assess the client's neurovascular status, including circulation, sensation, and movement, to determine if there is any compromise to the affected limb.
A client with cirrhosis and severe pruritus can be seen next, as pruritus can significantly affect the client's comfort and quality of life. However, it is not immediately life-threatening.
A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be assessed, but this finding is expected after a renal biopsy. The nurse should ensure that the client is monitored for any signs of bleeding or complications, but it may not require immediate attention unless the bleeding worsens or other concerning symptoms arise.
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge can be seen last, as long as there are no complications or signs of postoperative issues. The nurse should ensure that the client is stable, comfortable, and meeting the necessary criteria for discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.
Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.
Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.
It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.
Correct Answer is C
Explanation
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
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