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. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.
C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.
D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.
Correct Answer is B
Explanation
A. Levothyroxine is a medication used to treat hypothyroidism by replacing or supplementing thyroid hormone. It is not typically associated with decreased blood pressure.
B. Weight loss can be an indicator that levothyroxine therapy is effective in treating hypothyroidism. Hypothyroidism often leads to weight gain, and successful treatment with levothyroxine can help reverse this trend.
C. Levothyroxine therapy primarily targets thyroid hormone levels and is not directly associated with decreased inflammation.
D. Seizures are not typically associated with hypothyroidism or its treatment with levothyroxine.
The effectiveness of levothyroxine is primarily assessed by monitoring thyroid function tests and clinical symptoms such as weight loss, improved energy levels, and resolution of hypothyroid symptoms.
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