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 B

Explanation

As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.

The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.

A. Plug the IV pump's cord into a different outlet. B. Clear the settings and reset the IV pump. C. Discontinue use and tag the IV pump. D. Replace the IV pump's tubing.

Correct Answer is C

Explanation

A malfunctioning IV pump screen poses a risk to the accurate administration of IV fluids and medications, and it can compromise patient safety. It is important to discontinue use of the malfunctioning pump to prevent potential errors or complications. The nurse should tag the IV pump to notify others that it is not functioning properly and should not be used until it is repaired or replaced.

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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

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Correct Answer is C

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