A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

A client admitted for a cholecystectomy 2 days ago with decreased bowel sounds.

A client admitted for diabetes mellitus with a blood glucose of 140 mg/dL.

A client admitted for a left femur fracture with new-onset confusion.

A client admitted for dehydration with a BP of 105/77 mm Hg.

Answer and Explanation

The Correct Answer is C

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

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Correct Answer is C

Explanation

Choice A reason: While touch can be used to convey interest and warmth, it is essential to recognize that its appropriateness varies among individuals, especially those with psychiatric disorders. The focus should be on understanding the client's comfort level with touch.

Choice B reason: Combining touch with empathy can be beneficial in some cases, but it may not always be appropriate for clients with psychiatric disorders. The individual's perception and comfort with touch should be taken into account before using it as a therapeutic tool.

Choice C reason: This statement acknowledges that touch can have different meanings for different individuals. It emphasizes the need for sensitivity and awareness of the client's personal boundaries and preferences, which is crucial in therapeutic communication with clients diagnosed with psychiatric disorders.

Choice D reason: Touch is not typically used as a primary method for deescalating volatile situations. Non-verbal cues and verbal communication techniques are often more effective and safer methods for managing such scenarios.

A. Conduct a client care conference B. Provide information about advance directives C. Orient the client to his room D. Develop a plan of care

Correct Answer is C

Explanation

Choice A reason: Conducting a client care conference is important for multidisciplinary care planning, but it may not immediately address the client's safety needs upon admission. Safety measures should be implemented promptly to prevent potential accidents or confusion.

Choice B reason: Providing information about advance directives is crucial for ensuring that the client's wishes are respected during their care. However, this does not directly address immediate safety concerns that may arise from being in a new environment.

Choice C reason: Orienting the client to his room is essential to promote client safety. This includes familiarizing the client with the layout of the room, location of the bathroom, call bell, and any other essential features. It helps prevent falls and accidents by reducing confusion and ensuring the client knows how to access help if needed.

Choice D reason: Developing a plan of care is critical for long-term management of the client's health needs. However, immediate safety concerns should be addressed first to ensure a safe environment for the client from the outset.

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A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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