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 had a renal biopsy 3 hr ago and has pink-tinged urine
A client who has a femur fracture and reports numbness of the toes
A client who has cirrhosis and severe pruritus
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
The Correct Answer is B
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Correct Answer is C
Explanation
a.While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.
b.Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.
c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.
d.Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion
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