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 D
Explanation
This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.
It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.
The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.
Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.
The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.
Correct Answer is C
Explanation
Iron supplementation commonly causes constipation, which is due to the iron's effect of slowing down bowel movements and increasing water absorption in the intestines.
Dry mouth is not a common adverse effect of iron supplementation. It is more commonly associated with medications that can cause xerostomia (dry mouth), such as certain antihistamines or anticholinergic drugs.
Tinnitus, a perception of ringing or noise in the ears, is not typically associated with iron supplementation. Tinnitus can be caused by various factors, such as exposure to loud noises, ear infections, or certain medications, but it is not directly related to iron supplementation.
Hematuria, the presence of blood in the urine, is not a common adverse effect of iron supplementation. It can be caused by various conditions affecting the urinary system, such as urinary tract infections, kidney stones, or bladder issues, but it is not directly related to iron supplementation.
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