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 A

Explanation

A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.

B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.

C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.

D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.

A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry

Correct Answer is A

Explanation

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.

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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

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