A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
Recent exposure to tuberculosis
History of generalized anxiety disorder
Reports periodic migraine headaches
Experiences nocturia
Experiences nocturia
The Correct Answer is A
Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.
Reasons why the other options are not answers:
Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.
Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.
Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"I should consume no more than 2,000 milligrams of sodium per day." This is an appropriate statement because consuming too much sodium is associated with an increased risk for hypertension.
Choice A is not correct because there is not enough evidence to support the idea that consuming fish once per week can prevent hypertension.
Choice B is not correct because maintaining a healthy weight is important, but is not as directly related to preventing hypertension as reducing sodium intake.
Choice D is not correct because exercising 30 minutes three times per week is not enough to prevent hypertension.
Correct Answer is A
Explanation
Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.
Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.
Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.
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