A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first?
A client who has pneumonia and requires a tracheostomy dressing change
A client who has a new colostomy and requires discharge teaching
A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg
The Correct Answer is D
A. A tracheostomy dressing change is important for preventing infection but is not as urgent as a potential complication like deep vein thrombosis (DVT).
B. Discharge teaching is essential but not time-sensitive and can be safely delayed.
C. Diarrhea from enteral feedings may require adjustment of the formula, but the feeding isn’t due for 2 hours, making this less urgent.
D. A client who is 4 hr postoperative with pitting edema of the right leg should be seen first. This finding could indicate a deep vein thrombosis (DVT), a potentially life-threatening complication due to the risk of pulmonary embolism. This requires immediate assessment and intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.A tracheostomy dressing change is important for preventing infection but is not as urgent as a potential complication like deep vein thrombosis (DVT).
B.Discharge teaching is essential but not time-sensitive and can be safely delayed.
C.Diarrhea from enteral feedings may require adjustment of the formula, but the feeding isn’t due for 2 hours, making this less urgent.
D.A client who is 4 hr postoperative with pitting edema of the right legshould be seen first. This finding could indicate a deep vein thrombosis (DVT), a potentially life-threatening complication due to the risk of pulmonary embolism. This requires immediate assessment and intervention.
Correct Answer is C
Explanation
A.A living will can be completed at any time and is not required prior to treatment but is recommended to guide care decisions.
B.Notarization requirements vary by state; notarization alone does not finalize a living will.
C.A living will is a legal document that outlines the client’s preferences regarding medical treatment if they become unable to communicate.
D.A lawyer’s signature is not mandatory for a living will to be valid.
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