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 B
Explanation
A. While it's important for the client to empty their bladder before surgery to reduce the risk of complications, administering a preoperative injection typically requires monitoring the client closely for any adverse reactions rather than immediately taking them to the bathroom.
B. Asking the client to verify the surgical site helps prevent wrong-site surgery and ensures proper patient safety protocols are followed.
C. Reviewing deep breathing and coughing exercises is an important preoperative teaching, but it's not typically done immediately after administering a preoperative injection.
D. Raising the side rails on the bed is a safety measure to prevent falls, but it's not directly related to administering a preoperative injection.
Correct Answer is D
Explanation
A. Prohibiting visitors is not necessary for clients with sealed internal radiation implants. Visitors should be allowed unless specific restrictions are required based on the type of radiation therapy.
B. While maintaining distance from the radiation source is important, there is no specific guideline stating a 3-foot distance. The nurse should follow institutional policies and radiation safety guidelines regarding proximity to the radiation source.
C. There is no need to maintain the client on bed rest for 72 hours after receiving a sealed
internal radiation device. The client should be encouraged to ambulate and perform activities of daily living as tolerated.
D. Requiring the client to wear a dosimeter badge allows healthcare providers to monitor the amount of radiation exposure received by the client and ensures that radiation safety protocols are followed.
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