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 C
Explanation
Choice A reason: This is not an appropriate intervention because monitoring the neurovascular status of the client's affected limb every 8 hours is not frequent enough to detect any signs of impaired circulation, sensation, or movement in the limb that may result from injury, infection, or compartment syndrome. The nurse should monitor the neurovascular status of the client's affected limb at least every 2 hours and compare it with the unaffected limb.
Choice B reason: This is not an appropriate intervention because applying 4.5 kg (10 lb) traction weight to the distal end of the fixator is not indicated for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should avoid applying any weight or force to the fixator unless prescribed by the provider.
Choice C reason: This is an appropriate intervention because administering pain medication 30 minutes prior to pin care can reduce the discomfort and anxiety that the client may experience during the procedure, which involves cleaning and inspecting the pins and wires that hold the fracture fragments in place. The nurse should administer analgesics as prescribed and use aseptic technique and sterile equipment for pin care.
Choice D reason: This is not an appropriate intervention because adjusting the clamps on the device's frame daily is not within the scope of practice of a nurse who is caring for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should leave the clamps and screws on the device untouched and notify the provider if they become loose or damaged.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action for this client because placing them in a negative airflow room is indicated for clients who have airborne infections, such as tuberculosis or measles, that can spread through small particles that remain suspended in air. Streptococcal pharyngitis, also known as strep throat, is caused by bacteria that spread through large respiratory droplets that fall within 3 feet from source.
Choice B reason: This is an appropriate action for this client because implementing droplet precautions can prevent transmission of streptococcal pharyngitis to others by contact with respiratory secretions or contaminated objects. The nurse should wear a surgical mask when entering the client's room and instruct visitors to do so as well. The nurse should also place a mask on the client when transporting them outside their room.
Choice C reason: This is not an appropriate action for this client because placing them on a fluid restriction can cause dehydration and impair mucosal healing. The nurse should encourage the client to drink plenty of fluids, such as water, tea, or broth, to soothe the throat and prevent dryness.
Choice D reason: This is not an appropriate action for this client because obtaining a throat culture after the initial dose of antibiotics can affect the accuracy of the test results and delay diagnosis and treatment. The nurse should obtain a throat culture before starting antibiotics to confirm the presence of streptococcal bacteria and guide antibiotic therapy.
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