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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A.Faxing client information to a referred provider is not a breach of confidentiality as long as appropriate safeguards (e.g., cover sheet, correct fax number) are used.
B.Logging out of the computer before leaving maintains confidentiality and is appropriate practice.
C. This can expose protected health information to unauthorized individuals and is a breach of confidentiality.
D.If the nurse is not involved in the care of all those clients, accessing that information violates the "minimum necessary" standard under HIPAA.
E. Sharing client information with anyone not authorized by the client is a clear breach of confidentiality.
Correct Answer is C
Explanation
A.A confused and restrained client requires assistance and monitoring, which may delay evacuation.
B.A post-op client with a chest tube is not stable for quick evacuation without careful preparation and equipment.
C. A client receiving IV chemotherapy and is ambulatory– Yes. This client is stable and mobile, making them the highest priority for evacuation because they can move with minimal assistance.
D.A client in Buck’s traction is immobile and would require significant help and coordination to evacuate safely.
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