A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?
A client who had abdominal surgery 2 days ago and the incision line is separating
A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10
A client who has a chronic tracheostomy and is intermittently coughing up clear sputum
A client who has Clostridium difficile and has liquid stools
The Correct Answer is A
Choice A reason: This is the correct answer because a client who had abdominal surgery 2 days ago and the incision line is separating has a potential complication of wound dehiscence or separation of the surgical incision that can lead to evisceration or protrusion of the internal organs. This is a medical emergency that requires immediate intervention and notification of the provider.
Choice B reason: This is not a priority client to attend to because a client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 has a stable condition that can be managed with analgesics, ice packs, or elevation as prescribed. The nurse should assess the client's pain level, location, and quality and provide comfort measures as needed.
Choice C reason: This is not a priority client to attend to because a client who has a chronic tracheostomy and is intermittently coughing up clear sputum has an expected finding that indicates normal secretion clearance and respiratory function. The nurse should monitor the client's oxygen saturation, respiratory rate, and breath sounds and provide tracheostomy care as prescribed.
Choice D reason: This is not a priority client to attend to because a client who has Clostridium difficile and has liquid stools has an expected finding that indicates infection of the colon by bacteria that produce toxins that cause inflammation, diarrhea, and abdominal pain. The nurse should implement contact precautions, collect stool samples for testing, and administer antibiotics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because a Yankauer catheter is a rigid, curved suction device that is used to remove secretions from the mouth and throat. It is easy to handle and control and can be attached to a portable suction machine at home.
Choice B reason: This is not an appropriate equipment for oropharyngeal suctioning at home because sterile gloves are not necessary for this procedure. The nurse should instruct the client to use clean gloves and wash their hands before and after suctioning.
Choice C reason: This is not an appropriate equipment for oropharyngeal suctioning at home because water-soluble lubricant is not needed for this procedure. The nurse should instruct the client to moisten the tip of the catheter with sterile saline or water before inserting it into the mouth.
Choice D reason: This is not an appropriate equipment for oropharyngeal suctioning at home because oropharyngeal airway is not used for this procedure. An oropharyngeal airway is a device that keeps the tongue from blocking the airway and is used for unconscious clients who are not intubated.
Correct Answer is D
Explanation
Choice A reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because difficulty swallowing or dysphagia is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of difficulty swallowing, such as stroke, esophageal disorders, or dementia.
Choice B reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because diarrhea or frequent loose stools is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of diarrhea, such as infection, food intolerance, or medication side effects.
Choice C reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because hyperreflexia or increased reflexes is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of hyperreflexia, such as hyperthyroidism, spinal cord injury, or anxiety.
Choice D reason: This is an expected finding for a client who has a potassium level of 3.2 mEq/L because muscle weakness or decreased muscle strength is a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should monitor the client's vital signs, electrocardiogram (ECG), and serum potassium levels and administer potassium supplements as prescribed.
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