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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mixing ferrous sulfate capsules with food may alter the absorption of the medication. It is generally recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce
irritation.
B. Dissolving ferrous sulfate capsules in chocolate milk or any other liquid may affect the taste and consistency of the drink. Additionally, chocolate milk may contain substances that could
interfere with iron absorption.
C. Administering iron supplements with a glass of orange juice is a common recommendation because vitamin C enhances the absorption of iron. This combination helps improve the bioavailability of the iron supplement.
D. There is no specific indication to administer ferrous sulfate capsules at bedtime. It is typically recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce irritation.
Correct Answer is C
Explanation
A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.
B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.
C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.
D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.
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