A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A client who is short of breath
A client who received pain medication 30 min ago
A client who is ambulatory and going for an x-ray at 1000
A client who is to be discharged at 1100
The Correct Answer is A
A. Shortness of breath can indicate a serious respiratory issue, and this client may require immediate assessment and intervention. Respiratory distress can rapidly deteriorate a patient’s condition, making it essential to address this situation first.
B. While monitoring for pain relief and potential side effects is important, this client does not present an immediate threat to their health compared to the client experiencing shortness of breath. This client can be assessed after the more urgent cases.
C. Since the client is ambulatory and scheduled for an x-ray later, they can be seen after more critical needs have been addressed. Their situation is stable at this time.
D. While the discharge process is important, it can typically wait until more urgent situations are addressed. The nurse can prepare for the discharge but should focus on clients who have immediate health concerns first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clients should begin with manageable inhalation volumes and gradually increase them as their lung capacity improves. This approach helps to avoid fatigue and ensures the client becomes comfortable with the device.
B. Being too aggressive in increasing inhalation volumes can lead to discomfort, discourage use of the spirometer, and could result in ineffective deep breathing. It's important for clients to progress at a pace that feels comfortable to them.
C. This choice is inappropriate unless there is clear evidence that the spirometer is not functioning correctly. The focus should be on teaching the client how to use the device effectively rather than suggesting they switch devices prematurely.
D. While deep-breathing exercises are beneficial, they do not replace the use of an incentive spirometer. The spirometer is specifically designed to encourage deep breaths and improve lung expansion, which is especially important post-surgery or for individuals with respiratory issues.
Correct Answer is B
Explanation
A. While some conditions may lead to minimal bubbling, the absence of bubbling in the suction control chamber typically indicates that the suction is not functioning properly. It should be investigated rather than monitored passively.
B. The first step should be to check that the suction regulator is properly set and turned on. If the regulator is off or set too low, it can result in a lack of bubbling in the suction control chamber. Ensuring that suction is functioning correctly is crucial for effective drainage and pressure regulation.
C. This option may be necessary, but it is not the immediate first step. If the suction regulator is confirmed to be on and there is still no bubbling, the nurse should then notify the provider. However, it’s essential to troubleshoot the issue first.
D. While milking the chest tube can be indicated in certain circumstances to relieve occlusion, it should not be the first step in this situation. Before taking this action, it’s important to check the suction settings to rule out the source of the problem.
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