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 C
Explanation
The correct answer is Choice C because, "Evaluate the client's home environment." Since the client has a new prosthesis, the priority is to evaluate the client's home environment for safety and accessibility. Collaborating with a prosthetist to teach the client about care of the prosthesis (Choice A is wrong because) is important, but not the priority at this stage. Determining eligibility for a skilled nursing facility (Choice B is wrong because) and asking about insurance coverage for home health services (Choice D is wrong because) are important considerations, but not the priority assessment in this situation.
Choice A is wrong because: Collaborating with a prosthetist to teach the client about care of the prosthesis is important, but not the priority at this stage.
Choice B is wrong because: Determining whether the client is eligible to go to a skilled nursing facility is an important consideration, but not the priority assessment in this situation.
Choice D is wrong because: Asking about insurance coverage for home health services is an important consideration, but not the priority assessment in this situation.
Correct Answer is D
Explanation
The correct answer is Choice D because, "Household contacts will receive prophylactic antibiotics." The nurse should include in the teaching that household contacts of the child with pertussis will receive prophylactic antibiotics to prevent the spread of the disease. This answer is correct because pertussis is a highly contagious respiratory illness that spreads through respiratory droplets, and prophylactic antibiotics can help prevent the spread of the disease.
Choice A is wrong because is incorrect because a dehumidifier will not prevent the spread of pertussis.
Choice B is wrong because is incorrect because pertussis does not cause a rash.
Choice C is wrong because is incorrect because herd immunity occurs when a large percentage of the population is immunized against a disease, and pertussis is preventable with vaccination.
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