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 B
Explanation
A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.
Correct Answer is ["D","E","F","G","H"]
Explanation
Rationale
- Client reports pain as 5 on a scale of 0 to 10. The case manager can work with the healthcare team to ensure adequate pain management strategies are in place.
- Client requests a dose of their pain medication. This indicates ongoing pain and the need for effective pain management.
- Client expresses concern regarding the cost of prescription medications. The case manager can assist with identifying affordable medication options or connecting the client with financial assistance programs.
- Client reports being unable to find transportation to follow-up appointment. The case manager can help arrange transportation or connect the client with community resources that can provide transportation assistance.
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