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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.

A. Set up the sterile field 7.6 cm (3 in) below waist level. B. Hold the bottle of sterile solution with the palm over the label while pouring. C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border. D. Place the lid of a bottle of sterile solution within the sterile field.

Correct Answer is C

Explanation

A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.

B. Hold the bottle of sterile solution with the palm over the label while pouring - This is

incorrect because it increases the risk of contaminating the solution by touching the label.

C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.

D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.

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A nurse is receiving report on four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Correct Answer is C

Explanation

A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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