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 B
Explanation
Choice A rationale:
Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.
Choice C rationale:
Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.
Choice D rationale:
Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.
Correct Answer is C
Explanation
Answer isc. Keep the head of the bed raised while the tube feeding is infusing.
The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1.The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2.Aspiration can cause pneumonia, which is a serious complication that can be fatal3.
a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.
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