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 {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
A. It would not be appropriate to place the client on restraints as this would increase agitation and he is not violent.
B. The client may have a urinary tract infection (UTI) that is causing fever, hypotension, and confusion. Monitoring elimination can help assess the severity of the infection and the need for antibiotics.
C. Dimming the lights can help reduce sensory overload and agitation in the client.
Correct Answer is B
Explanation
A. Influenza immunizations: This is an example of primary prevention because it aims to prevent the occurrence of influenza infection in the first place.
B. Tuberculosis screenings: This is an example of secondary prevention because it involves early detection and treatment of tuberculosis infection to prevent its progression to active disease and
transmission to others.
C. Presentations about safer sex practices: This is an example of primary prevention aimed at reducing the risk of sexually transmitted infections by promoting safe behaviors.
D. Evaluations of bloodborne pathogen policies: This is an administrative activity related to ensuring workplace safety and adherence to policies and procedures and does not directly
involve prevention of communicable diseases among individuals.
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