A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?
A client who has early dementia and awoke confused to their location this morning
A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
A client who has pneumonia and has developed wheezing
A client who is postoperative and has a urine output of 50 mL for the past 3 h
The Correct Answer is C
A) A client who has early dementia and awoke confused to their location this morning:
Confusion in a client with early dementia could indicate a range of possible causes, such as infections, medication side effects, or changes in routine. However, while this warrants investigation, confusion alone does not represent an immediate life-threatening situation according to the ABCDE priority framework. The focus is on managing airway, breathing, circulation, and disability issues first.
B) A client who is scheduled for discharge and has a 38.4°C (101.1°F) temperature this morning:
A fever may indicate infection, which would require further assessment and potentially treatment. While this is a concern, it does not immediately threaten the client's airway, breathing, or circulation. Since the client is not in an acute crisis and is scheduled for discharge, this would be a lower priority compared to clients with more urgent issues like breathing problems or insufficient urine output.
C) A client who has pneumonia and has developed wheezing:
Wheezing indicates potential airway constriction, which could impair the client's breathing. Given that breathing difficulties are a primary concern in the ABCDE priority framework (Airway, Breathing, Circulation, Disability, and Exposure), this client requires immediate attention. Pneumonia combined with wheezing can signify a worsening respiratory condition, which poses an acute risk to the client's oxygenation and overall stability.
D) A client who is postoperative and has a urine output of 50 mL for the past 3 hours:
Oliguria (low urine output) postoperatively is concerning, as it may indicate kidney dysfunction, hypovolemia, or other complications. While it is an important issue that requires attention, it is not immediately life-threatening unless the client shows signs of worsening shock or kidney failure. However, given that this issue does not immediately affect the client’s airway or breathing, it is a lower priority than the client with pneumonia and wheezing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) They bend at the ho when lifting:
This statement seems to be a typographical error, but it likely refers to "bending at the hips" when lifting. While bending at the hips can help reduce strain on the back, it is not the ideal body mechanic for lifting heavy objects. Proper lifting techniques involve bending at the knees, not the hips, to maintain proper alignment and reduce the risk of injury to the lower back. The correct form would be to squat down using the legs and keeping the back straight.
B) They keep their feet together when lifting an object:
Keeping the feet together when lifting an object is not advisable. The nurse should keep their feet shoulder-width apart for stability when lifting heavy objects. This wide stance provides a stable base and helps prevent loss of balance or strain during the lift. Keeping feet together would increase the risk of losing balance and possibly causing injury.
C) They stand close to the object being moved:
Standing close to the object being moved is the correct body mechanic. When lifting, the nurse should position themselves close to the object to minimize the leverage needed to lift it. By maintaining a short distance from the object, the nurse can use their legs to lift rather than relying on their back, which helps reduce the risk of back strain or injury.
D) They twist their spine when lifting:
Twisting the spine when lifting is a dangerous action that increases the risk of back injury. Proper body mechanics require that the nurse keep the back straight and avoid twisting the spine during the lift. Instead, they should rotate their whole body, moving their feet to turn, rather than twisting the spine. Twisting puts unnecessary stress on the spinal discs and can lead to muscle strain or injury.
Correct Answer is A
Explanation
A) Researcher:
The nurse is gathering evidence-based practice (EBP) on catheter-associated urinary tract infections (CAUTI), which involves systematically collecting, analyzing, and reviewing existing studies or guidelines to inform clinical practice. This is the role of the researcher in EBP. Nurses in this role contribute to improving patient outcomes by identifying best practices, assessing existing evidence, and implementing findings to reduce complications, such as CAUTIs.
B) Nurse manager:
While a nurse manager may oversee quality improvement projects, staffing, and other operational aspects of nursing care, they are not typically the ones actively gathering evidence-based data themselves. Nurse managers may utilize the findings from research but are not directly involved in the research process unless leading specific studies.
C) Case manager:
A case manager primarily coordinates care for individual patients, ensuring they receive the appropriate resources and follow-up care. They help manage the continuity of care across different settings but do not focus on gathering or researching evidence for clinical practices. Their role is more focused on patient outcomes and care delivery rather than generating evidence.
D) Educator:
While an educator might be involved in teaching staff or patients about preventing CAUTI, the role described in the question specifically refers to gathering evidence-based practice information. Educators may use research findings in their teaching, but gathering evidence is a distinct activity that fits the role of the researcher in EBP.
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