A nurse is receiving a change-of-shift report for four clients. Which of the following findings should the nurse identify as the priority?
A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg.
A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10.
A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should ask the AP to perform the task of taking an ABG (arterial blood gas) specimen to the laboratory first. This is because ABG specimens need to be analyzed promptly to ensure accurate results. Timely analysis of ABG specimens is important for making clinical decisions and providing appropriate care to the client.
Option A is incorrect because giving fresh water to clients who do not have NPO status is not as time-sensitive as taking an ABG specimen to the laboratory.
Option B is incorrect because obtaining a routine urine sample from a client right after admission is not as time-sensitive as taking an ABG specimen to the laboratory.
Option C is incorrect because transporting a client to the radiology department for an x-ray is not as time-sensitive as taking an ABG specimen to the laboratory.
Correct Answer is A
Explanation
The nurse should have the AP perform the task of feeding a school-age client who has burns on both upper extremities first. This task is a high priority because it addresses the client's immediate need for nutrition and hydration. The client's burns may make it difficult for them to feed themselves, so the assistance of the AP is necessary to ensure that the client receives adequate nourishment.
The other tasks are also important, but they are not the highest priority in this situation. Collecting a stool sample for ova and parasites from a toddler [b] and bathing an adolescent client who is disabled [c] are routine tasks that can be performed as time permits. Ambulating a preschooler who is postoperative to the playroom [d] is also important for promoting mobility and recovery, but it is not as urgent as addressing the immediate need for nutrition and hydration.
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