A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?
A client who has type 2 diabetes mellitus needs assistance counting the carbohydrates in her meal.
A client who has a new tracheostomy is experiencing coughing episodes.
A client who has a BMI of 17 refuses his dinner tray.
A client awaiting discharge needs to demonstrate colostomy care before leaving.
The Correct Answer is B
A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.
Correct Answer is B
Explanation
A. Replace nonperishable food items annually: While rotating nonperishable food supplies is important, many nonperishable items have longer shelf lives, and replacement frequency depends on expiration dates. This is not the most essential point to include.
B. Have a backup supply of nonprescription medications: This is crucial for older adults who often rely on medications such as pain relievers, antacids, or allergy medications. In a disaster, access to pharmacies may be limited, making backup supplies essential for maintaining health.
C. Stock 2 liters of water per person per day: The recommended amount is generally at least 3.8 liters (1 gallon) of water per person per day for drinking and sanitation, not 2 liters.
D. Gather enough supplies to last for 2 weeks: While two weeks is ideal in some emergency plans, the standard recommendation by organizations such as FEMA is at least 3 days of supplies. Therefore, this advice may not be the most practical or commonly endorsed in a general teaching session.
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