A nurse is receiving report on four clients. Which of the following clients should the nurse assess first?

A client who has an ileal conduit and mucus in the pouch

A client who has an arteriovenous fistula that vibrates when palpated

A client who had a transurethral resection of the prostate with red-tinged urine in the bag

A client who has chronic kidney disease with cloudy dialysate outflow

Answer and Explanation

The Correct Answer is C

A. A client who has an ileal conduit and mucus in the pouch - While mucus in the ileal conduit pouch should be monitored, it is not an urgent priority compared to assessing for potential complications such as bleeding in another client.

B. A client who has an arteriovenous fistula that vibrates when palpated - A vibrating arteriovenous fistula indicates normal functioning and does not require immediate assessment.

C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag - Red-tinged urine may indicate bleeding, a potential complication after a transurethral resection of the prostate, requiring prompt assessment and intervention.

D. A client who has chronic kidney disease with cloudy dialysate outflow - While cloudy dialysate outflow may indicate infection or other complications in a client with chronic kidney disease on peritoneal dialysis, it is not as urgent as assessing for bleeding in the client with red- tinged urine.

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Correct Answer is A

Explanation

A. Hospice care improves quality of life through palliative care - This is a central aspect of hospice care, focusing on pain and symptom management to enhance the patient's comfort and quality of life.

B. Hospice care provides 24-hr, in-home care - While hospice care may provide support, it typically does not offer around-the-clock care in the home.

C. Hospice care is intended to postpone death - Hospice care aims to provide comfort and support in the final stages of life, not to postpone death.

D. Hospice care encourages the family to coordinate health care services - While family

involvement is important, hospice care typically involves a coordinated interdisciplinary team rather than relying solely on family for coordination.

A. Head compression B. Fetal hypoxia C. Abruptio placentae D. Postmaturity

Correct Answer is A

Explanation

A. Early decelerations are typically benign and occur due to head compression during

contractions. They mirror the uterine contraction pattern and are not usually associated with fetal compromise.

B. Fetal hypoxia is not typically associated with early decelerations, as they are considered a normal response to head compression during labor.

C. Abruptio placentae refers to the premature separation of the placenta from the uterine wall and is not directly related to early decelerations.

D. Postmaturity refers to a pregnancy that extends beyond 42 weeks gestation and is not directly related to early decelerations.

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Nursing Test Bank

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