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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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Smoked salmon: Smoked and cured meats are rich in tyramine, which can trigger a hypertensive crisis when combined with monoamine oxidase inhibitors (MAOIs) such as phenelzine. Clients must avoid aged, fermented, or smoked foods to prevent dangerous elevations in blood pressure related to MAOI therapy.

B. Grapefruit: Grapefruit primarily interacts with medications metabolized by the cytochrome P450 enzyme system, but it does not have a clinically significant interaction with MAOIs like phenelzine. Therefore, grapefruit is not restricted for clients taking this medication.

C. Spinach: Fresh vegetables, including spinach, contain negligible amounts of tyramine and are safe to consume with phenelzine. A diet rich in fresh fruits and vegetables is encouraged to support overall health and medication adherence.

D. Cottage cheese: Unlike aged cheeses, cottage cheese contains minimal tyramine and is considered safe for clients on MAOIs. It provides a good source of protein and calcium without the risk of precipitating hypertensive complications.

A. Oxygen saturation 97% on room air B. Pain level of 1 on a scale of 0 to 10 C. BMI 35 D. Capillary refill time 1 second

Correct Answer is C

Explanation

Rationale:
A. Oxygen saturation 97% on room air: Adequate oxygenation is essential for wound healing because oxygen supports collagen synthesis and tissue repair. An oxygen saturation of 97% indicates sufficient oxygen delivery to tissues and does not place the client at risk for delayed healing.

B. Pain level of 1 on a scale of 0 to 10: Minimal pain suggests effective postoperative pain management and allows the client to move, breathe deeply, and participate in recovery activities. Pain at this level does not negatively impact the wound-healing process.

C. BMI 35: Obesity is associated with delayed wound healing due to poor vascularity in adipose tissue, which reduces oxygen and nutrient delivery to the wound. Increased tension on wound edges and a higher risk of infection also contribute to impaired healing in obese clients.

D. Capillary refill time 1 second: A capillary refill of 1 second reflects adequate peripheral perfusion, which supports effective oxygen and nutrient delivery to tissues. Normal circulation facilitates the healing process rather than delaying it.

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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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