A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first?
A client who is 3 hr post Foley catheter removal and has not voided
A client who is 3 days postoperative colectomy with a large, loose melena stool
A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10
A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
The Correct Answer is D
A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.
B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.
C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.
Correct Answer is A
Explanation
A.
A. Hospice care improves quality of life through palliative care - This is a central aspect of hospice care, focusing on pain and symptom management to enhance the patient's comfort and quality of life.
B. Hospice care provides 24-hr, in-home care - While hospice care may provide support, it typically does not offer around-the-clock care in the home.
C. Hospice care is intended to postpone death - Hospice care aims to provide comfort and support in the final stages of life, not to postpone death.
D. Hospice care encourages the family to coordinate health care services - While family
involvement is important, hospice care typically involves a coordinated interdisciplinary team rather than relying solely on family for coordination.
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