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:
Replacing the ear molds once per year is not a standard recommendation for hearing aid maintenance. The frequency of ear mold replacement may vary depending on individual needs and wear and tear. It is not necessary to replace them annually unless there is a specific issue with the ear molds.
Choice B rationale:
Disinfecting the hearing aid with isopropyl alcohol is not recommended for routine cleaning. Isopropyl alcohol can damage the components of the hearing aid, including the microphone and receiver. Cleaning solutions specifically designed for hearing aids or a soft cloth are safer options for routine cleaning.
Choice C rationale:
Cleaning the hearing aid with a soft cloth is the correct action to take when caring for hearing aids. Routine cleaning with a soft cloth helps remove dust, debris, and earwax from the hearing aid's surface without causing damage to the components. It is a safe and effective method of maintaining hearing aid hygiene.
Choice D rationale:
Changing the battery once per month is not a fixed rule for all hearing aids. The frequency of battery replacement depends on the type of hearing aid, battery size, and individual usage patterns. Some batteries may last longer than a month, while others may need replacement sooner. Clients should be instructed to replace the battery when it no longer functions effectively.
Correct Answer is A
Explanation
Choice A rationale:
Grapes are a choking hazard for toddlers due to their small size and round shape. Young children can easily choke on grapes if they are not cut into smaller pieces or grapes are not adequately supervised during consumption. Educating parents and caregivers about cutting grapes into smaller, more manageable pieces is crucial to prevent choking incidents.
Choice B rationale:
Oranges (choice B) are generally not considered a high choking hazard for toddlers. However, parents and caregivers should still exercise caution and cut oranges into small, manageable pieces to reduce the risk of choking.
Choice C rationale:
Potatoes (choice C) can be a choking hazard for toddlers if not prepared and served appropriately. It is essential to cut potatoes into small, soft pieces and ensure that toddlers are supervised during mealtime to prevent choking incidents.
Choice D rationale:
Corn (choice D) can also pose a choking hazard for toddlers, especially if served on the cob. To minimize the risk, parents and caregivers should cut corn into small, bite-sized pieces or remove it from the cob before serving to young children.
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