A nurse is caring for four clients. Which of the following assessment findings is the priority?
A client who has facial drooping following a stroke 8 hours ago.
A client who has a femur fracture and reports feeling short of breath.
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.
The Correct Answer is B
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Notify the charge nurse of the client's request for transfer. This action might be taken eventually, but it is not the first step. The nurse should directly address the client's concerns before escalating the situation to the charge nurse.
Choice B rationale:
Assure the client that their concern has been shared with the staff. Tell the client that future calls will be answered in a timely manner. While it's important to reassure the client, promising timely responses to calls before understanding their expectations might not effectively address the underlying issue. It's better to communicate openly with the client first.
Choice C rationale:
Ask the client to verbalize their expectations. This is the correct choice. By asking the client to express their expectations, the nurse can gather crucial information about the client's concerns and needs. This allows the nurse to address the specific issues that led to the client's dissatisfaction and work toward a resolution that aligns with the client's preferences.
Correct Answer is B
Explanation
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
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