A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?
"The client who had abdominal surgery 3 days ago is reporting feeling constipated.”
"The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.”
"The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.”
"The client who is scheduled for discharge today states they are ready to sign their paperwork.”
The Correct Answer is C
Choice A rationale:
The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.
Choice B rationale:
The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.
Choice C rationale:
The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.
Choice D rationale:
The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Leaving the medication on the client's bedside table is not appropriate because it doesn't address the client's concerns and may result in the client not taking the medication at all. This choice does not promote the client's well-being.
Choice B rationale:
Returning in 1 hour to administer the medication doesn't address the client's immediate concerns and also doesn't provide adequate information about the medication's importance. Delaying the medication administration without proper communication is not ideal.
Choice C rationale:
Mixing the medication in applesauce may be appropriate in some cases, but it doesn't address the client's reluctance to take the medication due to fatigue. Additionally, the client's Crohn's disease might require specific instructions for medication administration that should not be altered without consulting the healthcare provider.
Choice D rationale:
The correct answer. Informing the client of the consequences of refusing the medication is the most appropriate action. The nurse should engage in a therapeutic conversation with the client, explaining the importance of the medication in managing Crohn's disease symptoms and preventing complications. This choice respects the client's autonomy while providing necessary information for an informed decision.
Correct Answer is B
Explanation
Choice A rationale:
Determining the swallowing ability of a client who has had a stroke requires clinical judgment and assessment skills that fall within the scope of a registered nurse's practice. This task involves assessing potential risks and complications related to the client's condition.
Choice B rationale:
Providing an enteral feeding to a client who has Crohn's disease is within the scope of an LPN's practice. LPNs are trained to administer enteral feedings and manage stable clients with chronic conditions, such as Crohn's disease, under the supervision of a registered nurse.
Choice C rationale:
Developing a teaching plan for a client with a new diagnosis of type 2 diabetes mellitus involves comprehensive assessment, education, and planning. This task requires the expertise of a registered nurse, as it encompasses various aspects of disease management and requires tailored education based on individual client needs.
Choice D rationale:
Weighing a client who is 3 days postoperative following coronary artery bypass grafting involves monitoring for postoperative complications and assessing the client's stability. This task requires clinical judgment and the ability to recognize potential issues, making it more appropriate for a registered nurse to perform.
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