A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?
A mother who reports that her son vomited after a dose of methylphenidate
A client who has COPD and reports an oxygen saturation of 90%
A client who reports that her new colostomy stoma appears purple
A client who reports feeling a vibration in his new internal arteriovenous graft for dialysis
The Correct Answer is B
The correct answer is choice B, a client who has COPD and reports an oxygen saturation of 90%. An oxygen saturation of 90% is below the normal range, which is typically between 95% to 100%. This indicates that the client is not receiving enough oxygen, which could lead to respiratory distress or hypoxemia. As the nurse, it is important to prioritize this client as a lower oxygen saturation level may result in further complications. The mother reporting vomiting in choice A may be concerning, but it is a known side effect of methylphenidate, and the client should be monitored for any further symptoms. The purple appearance of a colostomy stoma in choice C may indicate ischemia or necrosis, but it is not an urgent concern and can be assessed during the next visit. The feeling of a vibration in a new arteriovenous graft for dialysis in choice D may indicate an arterial steal syndrome, but it is not a medical emergency, and the client can be instructed to follow up with the provider. Therefore, the correct answer is choice B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C because "You should limit your use of extension cords." Extension cords are a common source of electrical hazards and should be used only when necessary. The nurse should advise the client to use power strips with built-in circuit breakers instead of extension cords.
Choice A is wrong because, "You should pull on the cord when unplugging items," is not the correct answer as pulling on the cord can damage the cord and create a hazard. Choice B is wrong because, "You should cover electrical cords with an area rug," is not the correct answer as this can create a trip hazard. Choice D is wrong because, "You should secure extension cords with clear packing tape," is not the correct answer as this does not address the underlying issue of using extension cords unnecessarily.
Correct Answer is A
Explanation
The correct answer is Choice A because "Assess the client's need for wound care supplies." Planning for wound care supplies is essential for a client who has a major burn injury. Wound care is crucial to prevent complications such as infection, and the case manager must ensure that the client has access to the appropriate wound care supplies.
Choice B is wrong because, "Provide physical and occupational therapy for the client in her home," is not the correct answer because physical and occupational therapy are interventions provided by therapists and not case managers. Choice C is wrong because, "Deliver family counseling to members of the client's household," is an example of psychosocial support and is not the primary responsibility of the case manager. Choice D is wrong because, "Administer personal care with bathing, dressing, and meal preparation for the client," is an intervention that is typically provided by home health aides and not case managers.
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