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 A
Explanation
An adult client who is short of breath should receive priority care because shortness of breath can be a sign of a life-threatening condition such as respiratory distress.
Choice B is incorrect because while an infant crying may indicate discomfort or distress, it is not necessarily a sign of a life-threatening condition.
Choice C is incorrect because while a head abrasion may require medical attention, it is not necessarily a life-threatening condition.
Choice D is incorrect because while a fractured arm may require medical attention, it is not necessarily a life-threatening condition.
Correct Answer is D
Explanation
The correct answer is choice D: “I should check the flow rate of my oxygen each day.”
Choice A rationale:
Keeping the oxygen delivery system at least 3 feet from a heating vent is a good safety practice, but it is not the best indicator that the client understands the teaching.The recommended distance is usually 5 to 10 feet to ensure safety.
Choice B rationale:
Using wool blankets is not recommended because wool can generate static electricity, which poses a fire hazard when using oxygen.
Choice C rationale:
Applying petroleum jelly to the nasal cannula prongs is not advised because petroleum-based products are flammable and can pose a fire risk when using oxygen.
Choice D rationale:
Checking the flow rate of the oxygen each day is crucial to ensure the client is receiving the correct amount of oxygen as prescribed.This practice demonstrates that the client understands the importance of monitoring their oxygen therapy.
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