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 laparoscopic appendectomy 8 hr ago and is awaiting discharge.
A client who had a renal biopsy 3 hr ago and has pink-tinged urine.
The Correct Answer is B
Choice A rationale:
The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.
Choice B rationale:
Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.
Choice C rationale:
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.
Choice D rationale:
Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Calling the supervisor to ask for another nurse is not the first action the charge nurse should take when noticing the smell of alcohol on a nurse's breath. While it's important to involve the supervisor, immediate action to ensure patient safety is required.
Choice B rationale:
Documenting objective findings about the situation is a valid step in the process, but it should not be the first action. The charge nurse's primary responsibility is to address the immediate safety concerns.
Choice C rationale:
Removing the nurse from the client care area is the first action the charge nurse should take when smelling alcohol on a nurse's breath. This action ensures patient safety and prevents potential harm caused by impaired nursing care.
Choice D rationale:
Assigning clients to the remaining staff is not the first action to take when there is suspicion of alcohol impairment in a nurse. Patient safety and addressing the situation involving the impaired nurse take precedence.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
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