A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?
A client who has heart failure and is incontinent of urine
A client who has COPD and dementia and was agitated during the night shift
A client who had a hip arthroplasty 10 days ago and reports pain with ambulation
A client who had a cerebrovascular accident 6 months ago and reports constipation
The Correct Answer is B
The nurse should atend to the client who has COPD and dementia and was agitated during the night shift first. This client may be experiencing respiratory distress or other complications related to their COPD and requires immediate assessment and intervention.
a) A client who has heart failure and is incontinent of urine requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
c) A client who had a hip arthroplasty 10 days ago and reports pain with ambulation requires atention, but their needs are not as urgent as those of the client with COPD and agitation.
d) A client who had a cerebrovascular accident 6 months ago and reports constipation requires attention, but their needs are not as urgent as those of the client with COPD and agitation.
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Related Questions
Correct Answer is C
Explanation
When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.
The other options are not correct because:
a) The client should not bear down during rectal tube insertion.
b) Administering a second enema if results are not clear is not mentioned as a safety precaution.
d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.
Correct Answer is D
Explanation
d. Corn tortillas with black beans.
Explanation:
Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.
Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
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