After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?
A Patient who developed a new cough after eating breakfast
B Patient who is refusing to take the prescribed medications.
C Patient who has not had a bowel movement for 5 days.
D Patient who has a stage Il pressure ulcer on the coccyx
The Correct Answer is A
Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.
Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.
Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.
Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
Correct Answer is D
Explanation
Choice A Rationale: Checking the patient's orientation to time and date is a part of assessing cognitive function but is not specific to the Mini-Cog exam.
Choice B Rationale: Obtaining a list of the patient's prescribed medications is important for the overall assessment but is not specific to the Mini-Cog exam.
Choice C Rationale: Determining the patient's ability to recognize a common object is not a component of the Mini-Cog exam.
Choice D Rationale: Asking the patient to draw a clock with a specific time is a key component of the Mini-Cog exam, which assesses cognitive impairment and is commonly used to screen for Alzheimer's disease.
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