A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A client who is postoperative following a laminectomy 12 hour and is unable to void

A client who is scheduled for a tubal ligation in 2 hours and is crying

A client who has peripheral vascular disease and has an absent pulse in the right foot

A client who has type 1 diabetes and needs the first dressing change for an ulcer

Answer and Explanation

The Correct Answer is C

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

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Correct Answer is A

Explanation

a. Anorexia nervosa is a complex psychiatric disorder, and the client would benefit from the expertise of a mental health counselor to address underlying psychological issues.
b. Nutritional therapy is crucial in the treatment of anorexia nervosa to address malnutrition and establish healthy eating habits.
c. While physical therapy may be necessary in some cases, it is not typically the primary focus of care for clients with anorexia nervosa.
d. A case manager may assist with coordinating care, but they may not have the specialized knowledge required to address the specific needs of a client with anorexia nervosa.
e. An occupational therapist focuses on helping clients perform activities of daily living and may not be directly involved in the treatment of anorexia nervosa unless there are specific functional limitations that need addressing.

A. "I will place a client who has a compromised immunity in a negative air pressure room" B. "I will wear a N95 respirator mask when caring for a client who is on droplet precautions" C. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions" D. "I will have a client who is on airborne precautions wear a mask when out of her room"

Correct Answer is D

Explanation

a. Clients with compromised immunity are often placed in protective environments, but not necessarily in negative air pressure rooms. These rooms are typically reserved for clients on airborne precautions.
b. An N95 respirator is required for airborne precautions, not droplet precautions. A regular surgical mask is sufficient for droplet precautions.

c. Contact precautions primarily focus on preventing the transmission of pathogens through direct or indirect contact. Visitors are usually instructed to wear personal protective equipment (PPE) when entering the room, but the focus is on healthcare workers wearing PPE during patient care.
d. A client on airborne precautions (e.g., for tuberculosis or measles) should wear a mask (preferably an N95 or equivalent) when leaving the room to prevent spreading airborne pathogens

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A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care?

Correct Answer is A

Explanation

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teachings?

Correct Answer is D

Explanation

A nurse is caring for a client who wanders through the halls yelling obscenities at staff and visitors. Which of the following actions should the nurse take?

A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?

A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescriptions in the client’s medical record?

20) A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is the appropriate procedure for taking care of the client's ring?

A hospice nurse is caring for a client who has terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?