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A nurse in a medical-surgical unit is caring for 6 clients.

Exhibits

Complete the following sentence by using the lists of options.

The first client the nurse should assess is

followed  by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

    1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
    2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
    3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

    1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
    2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
    3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

  1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
    2.  Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
    3.  Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
    4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
    5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
    6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)


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Related Questions

Correct Answer is A

Explanation

A. "Use IV tube ports when injecting medications." Latex-free IV ports should be used instead of rubber stoppers found in some IV bags and vials.
B. "Remove medication from multi-dose vials with the stopper in place." Many vial stoppers contain latex, so the nurse should use single-dose vials or vials labeled as latex-free.
C. "Secure loose cords in stockinette with tape." Stockinettes are sometimes made with latex, posing a risk to the client. Non-latex materials should be used instead.
D. "Schedule the client's surgery as the last procedure of the day." Clients with latex allergies should be scheduled first to minimize exposure to airborne latex particles from gloves and equipment used earlier in the day.

Correct Answer is A

Explanation

A. Case manager A case manager helps coordinate home oxygen therapy, arranges for home health services, and ensures the client has access to needed resources, such as durable medical equipment and personal assistance for ADLs.
B. Hospice care facility Hospice is appropriate for clients with a terminal illness and a life expectancy of 6 months or less. COPD is chronic but not necessarily end-stage.
C. Long-term care facility This client is not indicated for long-term institutional care but rather for home-based support.
D. Pharmacist While a pharmacist is important for medication education, they do not coordinate oxygen therapy or ADL assistance.

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