A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

A client who has cirrhosis and severe pruritus

A client who has a femur fracture and reports numbness of the toes

A client who had a renal biopsy 3 hr ago and has pink-tinged urine

A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

Answer and Explanation

The Correct Answer is B

Numbness of the toes following a femur fracture can indicate potential nerve compromise or damage, which requires immediate attention. Nerve compression or injury can lead to long-term complications if not addressed promptly. It is important for the nurse to assess the client's neurovascular status, including circulation, sensation, and movement, to determine if there is any compromise to the affected limb.

A client with cirrhosis and severe pruritus can be seen next, as pruritus can significantly affect the client's comfort and quality of life. However, it is not immediately life-threatening.

A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be assessed, but this finding is expected after a renal biopsy. The nurse should ensure that the client is monitored for any signs of bleeding or complications, but it may not require immediate attention unless the bleeding worsens or other concerning symptoms arise.

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge can be seen last, as long as there are no complications or signs of postoperative issues. The nurse should ensure that the client is stable, comfortable, and meeting the necessary criteria for discharge.

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Correct Answer is C

Explanation

Roasted Salmon

The nurse should include roasted salmon on the tray for the client who follows a kosher diet.

Kosher dietary laws prohibit the consumption of shellfish such as clams and shrimp, as well as pork products like pulled pork sandwiches. Roasted salmon, on the other hand, is a permissible food item in a kosher diet.

It's important for the nurse to be aware of the client's dietary restrictions and preferences to ensure that they receive appropriate and culturally sensitive care.

A. Have the client's partner sign an AMA form B. Discharge the client and notify the health care provider. C. Ask the partner to reiterate the consequences of leaving AMA to the client. D. Request the services of an interpreter to determine the client's wishes.

Correct Answer is D

Explanation

Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.

Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.

Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.

Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.

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A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Correct Answer is C

Explanation

A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immediately to the provider? Select all that apply.

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements indicates an understanding of the teaching?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?