A nurse receives change-of-shift report. Which of the following clients should the nurse attend to first?

A client who has a productive cough and an oral temperature of 36° C (96.8°F).

A client who reports tingling in the fingers following a thyroidectomy.

A client who is in a long leg cast and has +2 pedal pulses bilaterally.

A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr

Answer and Explanation

The Correct Answer is B

A. A client who has a productive cough and an oral temperature of 36° C (96.8°F): A normal temperature and stable vital signs indicate that this client’s condition is not immediately life-threatening. Assessment is important but not the priority.

B. A client who reports tingling in the fingers following a thyroidectomy: Tingling in the fingers may indicate hypocalcemia from potential injury or removal of the parathyroid glands during thyroidectomy. This is an acute complication that can lead to tetany or cardiac dysrhythmias, making it the highest priority.

C. A client who is in a long leg cast and has +2 pedal pulses bilaterally: Adequate pedal pulses indicate good circulation. While monitoring for neurovascular compromise is necessary, this client is currently stable.

D. A client who has dark, foul-smelling urine and a urine output of 320 mL in the last 8 hr: Oliguria and infection risk are concerning and require follow-up, but these findings do not pose an immediate threat compared with potential hypocalcemia after thyroid surgery.

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Correct Answer is B

Explanation

A.A gastric residual volume (GRV) of 250 mL is a finding that requires monitoring but typically does not require "immediate" intervention or the cessation of feeding. Current evidence-based guidelines often suggest that feedings should not be held unless the GRV exceeds 500 mL in a single measurement or if the client shows signs of intolerance (e.g., abdominal distension, nausea). While 250 mL indicates a slight delay in gastric emptying, it is not an acute emergency compared to the risk of aspiration from supine positioning.

B.The client is lying in a supine position: The client lying in a supine position requires immediate intervention. Clients receiving enteral feedings must have the head of the bed elevated to at least 30° to 45° at all times to prevent gastric reflux and aspiration. In a post-laryngectomy client, the risk is even higher because the anatomical changes to the upper airway make it easier for regurgitated feeding to enter the trachea. The nurse must immediately raise the head of the bed to ensure the client's safety.

C. The infusion pump for administering continuous feeding is turned off: The pump being turned off interrupts nutrition delivery, which is undesirable, but it does not pose an immediate risk to the client’s safety. Correcting the pump can be done after addressing more urgent issues.

D. The enteral feeding bag and tubing are not dated: Lack of dating increases the risk of infection due to prolonged use, but this is a routine safety concern and does not require immediate intervention compared with high gastric residual volumes that pose aspiration risk.

A. Shellfish allergy B. History of smoking C. Cardiac dysrhythmia D. Family history of malignant hyperthermia

Correct Answer is A

Explanation

A. Shellfish allergy: Glucosamine supplements are often derived from shellfish. Clients with a shellfish allergy may experience an allergic reaction if they take glucosamine, making this an important contraindication to assess before recommending the supplement.

B. History of smoking: Smoking does not directly contraindicate glucosamine use. While smoking has other health risks, it does not increase the risk of adverse effects from this supplement.

C. Cardiac dysrhythmia: Glucosamine is not known to cause cardiac dysrhythmias, and a history of dysrhythmias is generally not a contraindication. Standard monitoring is sufficient.

D. Family history of malignant hyperthermia: Malignant hyperthermia is triggered by certain anesthetic agents, not dietary supplements like glucosamine. This family history does not affect the safety of glucosamine intake.

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A nurse receives change-of-shift report. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is B

Explanation

A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications?

Correct Answer is A

Explanation

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