A nurse is receiving report on four clients. Which of the following clients should the nurse assess first?
A client who has an ileal conduit and mucus in the pouch
A client who has an arteriovenous fistula that vibrates when palpated
A client who had a transurethral resection of the prostate with red-tinged urine in the bag
A client who has chronic kidney disease with cloudy dialysate outflow
The Correct Answer is C
A. A client who has an ileal conduit and mucus in the pouch - While mucus in the ileal conduit pouch should be monitored, it is not an urgent priority compared to assessing for potential complications such as bleeding in another client.
B. A client who has an arteriovenous fistula that vibrates when palpated - A vibrating arteriovenous fistula indicates normal functioning and does not require immediate assessment.
C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag - Red-tinged urine may indicate bleeding, a potential complication after a transurethral resection of the prostate, requiring prompt assessment and intervention.
D. A client who has chronic kidney disease with cloudy dialysate outflow - While cloudy dialysate outflow may indicate infection or other complications in a client with chronic kidney disease on peritoneal dialysis, it is not as urgent as assessing for bleeding in the client with red- tinged urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. There is no known significant interaction between garlic supplements and antidepressants.
B. There is no evidence to suggest that garlic supplements are contraindicated for individuals with a history of seizure disorders. Garlic is not known to exacerbate seizure activity or interact with anticonvulsant medications.
C. Garlic has antiplatelet properties, which can increase the risk of bleeding, especially when combined with other blood-thinning agents like aspirin. Clients who take aspirin daily are at an increased risk of bleeding complications if they also take garlic supplements. This makes it a contraindication in such cases.
D. There are no known contraindications specifically related to rheumatoid arthritis and garlic supplements.
Correct Answer is D
Explanation
A. 1 cm of water present in the water seal chamber is within the expected range.
B. Tidaling with spontaneous respirations indicates the system is functioning properly.
C. Suction chamber pressure of -20 cm H2O is within the expected range for adequate suction.
D. The drainage collection chamber being one-third full suggests an accumulation of fluid beyond the expected level, which may indicate a potential complication such as hemorrhage or fluid buildup in the pleural space, requiring intervention by the nurse.
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