A nurse has just received the morning change of shift report for four clients. Which of the following clients has the highest priority need?
A client who has a serum potassium level of 5 mEq/L and is scheduled for dialysis in the afternoon.
A client who returned 1 hour ago from lithotripsy and is reporting nausea.
A client who had a total abdominal hysterectomy 2 days ago and is reporting a pain level of 3 on a scale of 0 to 10.
A client who has an indwelling urinary catheter and has a total urine output of 80 mL over the past 8 hours.
The Correct Answer is D
Choice A reason: While a serum potassium level of 5 mEq/L is at the higher end of the normal range, the client is scheduled for dialysis, which should address the issue.
Choice B reason: Nausea after lithotripsy is a concern, but it may not be as urgent as other conditions.
Choice C reason: A pain level of 3 is manageable and not the highest priority compared to other more acute needs.
Choice D reason: A urine output of 80 mL over 8 hours is significantly low and could indicate acute kidney injury or urinary retention, which requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A hemorrhoidectomy performed one year ago is unlikely to cause a false positive result on a fecal occult blood test at this time.
Choice B reason: A history of breast cancer does not affect the results of a fecal occult blood test.
Choice C reason: Consuming citrus juice does not cause a false positive result on fecal occult blood tests.
Choice D reason: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, which can lead to a false positive result on a fecal occult blood test.
Correct Answer is D
Explanation
Choice A reason: Clients are typically instructed to fast before a colonoscopy, so eating a light breakfast is not advised.
Choice B reason: Feeling bloated can be a normal sensation after a colonoscopy due to air introduced during the procedure.
Choice C reason: A sore throat is not a common side effect of a colonoscopy as a breathing tube is not used during this procedure.
Choice D reason: It is important for clients to arrange transportation home after a colonoscopy due to the sedatives used during the procedure.
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