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 laparoscopic appendectomy 8 hr ago and is awaiting discharge.
A client who had a renal biopsy 3 hr ago and has pink-tinged urine.
The Correct Answer is B
Choice A rationale:
The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.
Choice B rationale:
Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.
Choice C rationale:
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.
Choice D rationale:
Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
While music therapy can be a helpful adjunct for pain management, it is not a replacement for all pain medications. Pain management should be individualized, and the statement that music therapy alone will eliminate the need for all medication is not accurate.
Choice B rationale:
Discontinuing music therapy when the patient is no longer responsive may not be the best approach. Music therapy can still provide comfort and support even if the patient is not responsive in the traditional sense. It should be continued if it benefits the patient.
Choice C rationale:
Playing music is not intended to increase alertness but rather to provide comfort and relaxation. This statement reflects a misunderstanding of the purpose of music therapy in pain management.
Choice D rationale:
This statement correctly indicates an understanding of the purpose of music therapy. Music can distract the patient from pain and provide a sense of comfort and relaxation without completely eliminating awareness of pain.
Correct Answer is B
Explanation
Choice A rationale:
Informing the client that the procedure will take 60 minutes is not a critical action before an esophagogastroduodenoscopy (EGD) The duration of the procedure may vary, but this information is not as essential as other pre-procedure considerations.
Choice B rationale:
The correct action is to "Ensure that the client gave informed consent." Before any invasive procedure like an EGD, it is crucial to confirm that the client has provided informed consent. This ensures that the client understands the procedure, its risks, and benefits, and has the opportunity to ask questions and make an informed decision.
Choice C rationale:
Administering an oral contrast solution is not typically done before an EGD. An EGD involves the insertion of a flexible scope through the mouth into the esophagus, stomach, and duodenum to visualize these structures. Contrast solutions are usually used in other imaging procedures, such as barium swallow studies.
Choice D rationale:
Ensuring that the client's bladder is full is not necessary for an EGD. This requirement may be relevant for other imaging studies, but it does not apply to this procedure. The focus should be on the client's comfort, safety, and informed consent before the EGD.
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