After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?
A Patient who developed a new cough after eating breakfast
B Patient who is refusing to take the prescribed medications.
C Patient who has not had a bowel movement for 5 days.
D Patient who has a stage Il pressure ulcer on the coccyx
The Correct Answer is A
Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.
Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.
Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.
Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
Correct Answer is C
Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
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