A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

A client who is receiving a blood transfusion and reports low-back pain

A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL)

A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing

A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

Answer and Explanation

The Correct Answer is A

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

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Correct Answer is A

Explanation

Rationale:
A. Limited hip abduction: Restricted hip movement in an infant can indicate developmental dysplasia of the hip (DDH). Early detection is essential because delayed treatment may lead to permanent hip deformities, gait abnormalities, and the need for surgical intervention.

B. Symmetric gluteal and thigh skin folds: Symmetry of gluteal and thigh folds is a normal finding in infants. Asymmetry may be a sign of DDH, but symmetric folds generally indicate normal hip development and do not require referral.

C. Equal leg length: Equal length of both legs is a normal musculoskeletal finding. Leg length discrepancy can be associated with hip dislocation or dysplasia, but equal lengths suggest proper femoral positioning.

D. Femoral head remains in the acetabulum during the Barlow maneuver: A stable femoral head during the Barlow test indicates normal hip stability. If the femoral head dislocates or is reducible, referral for orthopedic evaluation would be warranted.

A. The client takes multiple steps while holding the walker. B. The client lifts the walker as it is moved forward. C. The client advances the walker and takes a step towards it. D. The client grasps the walker by the hand grips on the upper bars.

Correct Answer is A

Explanation

Rationale:
A. The client takes multiple steps while holding the walker: Taking several steps while holding the walker increases the risk of imbalance and falls. The correct technique is to move the walker forward one step length, ensure all four legs are stable on the ground, and then take a single step toward it before moving the other leg.

B. The client lifts the walker as it is moved forward: The walker should be lifted slightly and placed firmly on the ground to ensure stability with each step. Sliding the walker instead of lifting it can cause uneven movement or tipping, especially on rough surfaces, making lifting the correct method.

C. The client advances the walker and takes a step towards it: This is the proper technique for safe use. The client should advance the walker first, then step forward with the weaker leg, followed by the stronger leg, maintaining balance and even weight distribution.

D. The client grasps the walker by the hand grips on the upper bars: Proper hand placement on the upper hand grips ensures stability and correct posture during ambulation. Holding the walker anywhere else can cause poor control, imbalance, or wrist strain.

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A nurse on a medical-surgical unit is receiving reports for four clients. Which of the following clients should the nurse assess first?

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