A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first?
A client who has multiple sclerosis and reports ataxia and vertigo
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
A client who has left-sided paralysis and slurred speech from a prior stroke
A client who has thrombocytopenia and reports a nosebleed
The Correct Answer is D
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
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Related Questions
Correct Answer is B
Explanation
A chest physiotherapy vest is a device that delivers high-frequency chest wall oscillation to loosen and mobilize mucus from the airways . This helps improve lung function and prevent respiratory infections in patients with cystic fibrosis, who have thick and sticky mucus production . A peak flow meter is used to measure the peak expiratory flow rate, which reflects the degree of airway obstruction in patients with asthma .
An NG tube with suction apparatus is used to decompress the stomach and remove gastric contents in patients with bowel obstruction, paralytic ileus, or gastroparesis . A chest tube with a drainage system is used to remove air or fluid from the pleural space in patients with pneumothorax, hemothorax, or pleural effusion .
Correct Answer is B
Explanation
A monthly calendar can help the client with Alzheimer's disease to orient to time and date and reduce confusion and anxiety. The nurse should encourage the family to use simple and clear reminders and cues to assist the client with daily activities and routines.
Covering electrical outlets with tape is not necessary and may pose a fire hazard. Keeping the client's bedroom dark at night may increase the risk of falls and injuries. A large-face clock may be helpful, but not as much as a calendar.
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