After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

A client who has a history of pancreatitis and reports severe abdominal pain

A client who has heart failure and reports severe dyspnea

A client who is scheduled for abdominal surgery in 1 hr

A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dL

Answer and Explanation

The Correct Answer is B

A.   While severe abdominal pain in a client with a history of pancreatitis requires urgent assessment, severe dyspnea in a client with heart failure may indicate impending respiratory distress, requiring immediate intervention.
B.   Severe dyspnea in a client with heart failure is a critical situation that requires immediate assessment and intervention to prevent respiratory compromise or failure.
C.   While a client scheduled for surgery may need preparation and assessment, the client with severe dyspnea takes priority due to the potential for respiratory distress.
D.   While a high blood glucose level in a postoperative client with diabetes mellitus requires monitoring and intervention, the client with severe dyspnea requires immediate attention due to the potential for respiratory compromise.

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Correct Answer is D

Explanation

Answer: D. "Clean the prosthesis using a damp, soapy cloth."

Rationale:

A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.

B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.

C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.

D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.

A. Coordinating client care B. Providing direct client care C. Assessing a client's health status D. Identifying specific client health problems E. Identifying specific client health problems

Correct Answer is B

Explanation

A. Coordinating client care is typically a responsibility of registered nurses (RNs) who have advanced training and education in care coordination and management.
B. Providing direct client care, under the supervision of registered nurses or physicians, is a primary responsibility of licensed practical nurses (LPNs). This may include administering medications, assisting with activities of daily living, and monitoring clients' vital signs.
C. Assessing a client's health status is within the scope of practice of both registered nurses and licensed practical nurses, but LPNs typically perform more focused assessments compared to
RNs.
D. Identifying specific client health problems often involves critical thinking and clinical judgment, which are skills typically developed through higher levels of education and experience. While LPNs may identify issues during routine care, diagnosing health problems is generally the responsibility of the healthcare provider.

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After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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