A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A client who has a hip fracture and a new onset of tachypnea.

A client who has diabetes mellitus and an HbA1c of 6.8%.

A client who has epidural analgesia and weakness in the lower extremities.

A client who has sinus arrhythmia and is receiving cardiac monitoring.

Answer and Explanation

The Correct Answer is A

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism. The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is well- controlled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A.

Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

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Correct Answer is B

Explanation

An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

A. Drink four 240 mL (8 oz) glasses of water each day. B. Void every 5 to 6 hr during the day. C. Wear loose-fitting underwear. D. Take a bubble bath after intercourse.

Correct Answer is C

Explanation

This is because tight-fitting underwear can trap moisture and create a favorable environment for bacterial growth, which can increase the risk of urinary tract infections (UTIs) . Loose-fitting underwear can allow air circulation and prevent moisture accumulation .

Choice A is wrong because drinking four 240 mL (8 oz) glasses of water each day is not enough to prevent UTIs. The recommended amount of water intake for adults is about 2 to 3 liters per day . Drinking enough water can help flush out bacteria from the urinary tract and prevent them from adhering to the bladder wall .

Choice B is wrong because voiding every 5 to 6 hours during the day is too infrequent and can increase the risk of UTIs. The nurse should advise the client to void every 2 to 3 hours during the day. This can help prevent urinary stasis and bacterial multiplication in the bladder .

Choice D is wrong because taking a bubble bath after intercourse can increase the risk of UTIs. The nurse should instruct the client to avoid bubble baths, vaginal douches, or sprays, as they can irritate the urethra and introduce bacteria into the urinary tract . The nurse should also advise the client to empty the bladder before and after sexual intercourse, as this can help remove bacteria that may have entered the urethra during sexual activity .

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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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