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 C
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. A client who has COPD and reports an oxygen saturation of 90%. An oxygen saturation of 90% in COPD is within normal due to the chronic hypoxia.The purple appearance of a colostomy stoma in choice C may indicate ischemia or necrosis, and is an urgent concern.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 B
Explanation
The correct answer is Choice B because "Provide a smoking cessation class." Secondary prevention activities aim to detect and treat a disease in its early stages. In the case of smoking cessation classes, it is a secondary prevention activity because it aims to detect and treat the harmful effects of smoking before it progresses to a more serious condition such as lung cancer or chronic obstructive pulmonary disease.
Choice A is wrong because, "Advocate for laws that prohibit texting while driving," is not the correct answer because it is an example of primary prevention, which aims to prevent the onset of a disease or injury. Choice C is wrong because, "Refer a client who is recovering from a substance use disorder to a social service program," is an example of tertiary prevention, which aims to prevent complications or further progression of a disease. Choice D is wrong because, "Encourage a pregnant client to participate in prenatal care," is also an example of primary prevention, which focuses on preventing the onset of a disease or condition.
Correct Answer is A
Explanation
The correct answer is Choice A because, "I will be taking medication daily for at least 6 months." Tuberculosis is a bacterial infection that requires treatment with antibiotics for at least 6 months to ensure that the bacteria are completely eradicated. The client's statement indicates that they understand the importance of completing the full course of treatment.
Choice B is wrong because, "I will need to have a special HEPA filter installed in my home," is not the correct answer because although HEPA filters can help reduce the spread of tuberculosis, it is not a priority in client education.
Choice C is wrong because, "I will make sure to stop taking my medication as soon as I start feeling better," is not the correct answer because stopping medication too soon can lead to the development of drug-resistant tuberculosis and the return of symptoms.
Choice D is wrong because, "I can stop taking my medication once my cough goes away," is not the correct answer because a cough can persist even after the bacteria have been eliminated, and stopping medication too soon can lead to a relapse of the disease.
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