After receiving morning report about four clients, which client should the nurse attend to first?
An older female client who had a hip replacement yesterday and is notably pale with a Hemoglobin of 10.5 g/dl.
An adult client with osteomyelitis of the ankle who refuses an IV restart that is needed to administer antibiotics.
An elderly client with low back pain who removed the pelvic traction and repeatedly states a strong desire to go home.
A young adult client with a closed reduction of a fractured femur who has been complaining of increasingly severe pain.
The Correct Answer is D
Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.
Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.
Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.
Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.
Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.
Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.
Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.
Correct Answer is ["591"]
Explanation
One ounce is equivalent to 29.57 mL, so 12 ounces of coffee is equal to 354.84 mL. The cup of milk is usually measured as 8 ounces, which is 236.59 mL.
The oatmeal may also contain some fluid, but the amount is not given, so it cannot be counted.
Therefore, the total fluid intake at breakfast is 354.84 + 236.59 = 591.43 mL.
The nurse should document this value in the client's record, rounding it to the nearest whole number, which is 591 mL.
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