A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client who has new onset of dyspnea 24 hours after a total hip arthroplasty.

A client who has a urinary tract infection and low-grade fever.

A client who has acute abdominal pain of 4 on a scale from 0 to 10.

A client who has pneumonia and an oxygen saturation of 96%.

Answer and Explanation

The Correct Answer is C

Choice A reason:

A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.

Choice B reason:

A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.

Choice C reason:

A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.

Choice D reason:

A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.

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Correct Answer is D

Explanation

Choice A Reason

Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention.

Choice B Reason

Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void.

Choice C Reason

Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively.

Choice D Reason

Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.

A. Move quickly to a position in front of the client. B. Remain upright as the client falls toward them. C. Allow the client to slide down their outstretched leg. D. Place their arms around the client to prevent the fall.

Correct Answer is C

Explanation

Choice A Reason:

Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.

Choice B Reason:

Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.

Choice C Reason:

Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.

Choice D Reason:

Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.

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A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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