A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
Client reports that her new colostomy stoma appears purple.
Client who has COPD and reports an oxygen saturation of 90.
Client reports feeling a vibration in his new internal arteriovenous graft for dialysis.
Mother reports that her son vomited after a dose of methylphenidate.
The Correct Answer is A
A stoma that turns dark red, purple, or even black in color can be a sign of a problem with blood supply to the stoma 1. This can be a serious issue that requires immediate medical attention.
Choice B is not the correct answer because an oxygen saturation of 90 for a client with COPD is within an acceptable range.
Choice C is not the correct answer because feeling a vibration in a new internal arteriovenous graft for dialysis is not necessarily a cause for immediate concern.
Choice D is not the correct answer because vomiting after a dose of methylphenidate may be a side effect of the medication and may not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When arranging for the delivery of medical equipment to the client’s home, the nurse case manager is functioning in the role of a coordinator. In this role, the nurse coordinates the delivery of services and resources to meet the needs of the client.
Choice A is not the correct answer because an advocate represents and defends the rights and interests of the client.
Choice B is not the correct answer because a site locator identifies and secures appropriate locations for services or resources.
Choice C is not the correct answer because an educator provides information and teaches skills to clients and their families.
Correct Answer is D
Explanation
Low literacy can be a barrier to learning because it can make it difficult for clients to understand written materials and instructions.
Choices A, B, and C are not client-related barriers to learning.
Limited experience (choice A) and lack of credibility (choice B) are barriers that may affect the nurse’s ability to teach effectively, but they are not directly related to the client’s ability to learn.
Fear of public speaking (choice C) may affect the client’s willingness to participate in group discussions, but it is not a barrier to learning itself.
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