The nurse cares for a group of clients who have topical medications ordered. Which client should the nurse see first?

A client with an infection on the foot with an order for antifungal cream

A client with new chest pain with a STAT order for nitroglycerin paste

A client with chronic pain with a scheduled order for a fentanyl patch

A client with an order for collagenase to be applied during wound care

Answer and Explanation

The Correct Answer is B

Rationale:
A. A client with an infection on the foot who has an order for antifungal cream requires treatment, but this is not an immediate life-threatening situation. While topical antifungals are important for managing infection, the client’s condition is stable and can be addressed after more urgent needs are met.

B. A client with new chest pain who has a STAT order for nitroglycerin paste should be seen first. New chest pain may indicate myocardial ischemia or an acute coronary event, which is a potentially life-threatening condition. Administering the nitroglycerin promptly is critical to relieve pain, improve coronary blood flow, and prevent complications such as myocardial infarction. STAT orders indicate immediate priority, making this client the highest priority among those listed.

C. A client with chronic pain who has a scheduled fentanyl patch requires ongoing pain management, but this is a non-urgent, routine intervention. Delaying the application by a short time is less likely to result in immediate harm compared with a client experiencing new chest pain.

D. A client with an order for collagenase during wound care also requires timely intervention for proper wound healing, but the condition is not life-threatening. Wound care can be safely scheduled after urgent interventions, such as addressing new chest pain, are completed.

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Correct Answer is C

Explanation

Rationale:
A. Placing the client’s first urine void in the collection container is incorrect because the first void of the day is always discarded in a 24-hour urine collection. The collection period begins with the second void, which is retained and then all subsequent urine is collected for the next 24 hours. Including the first void would result in inaccurate measurement of substances such as creatinine, protein, or electrolytes, which could affect diagnostic results.

B. Placing an external urinary catheter with a collection bag is outside the UAP’s scope of practice and is unnecessary for a routine 24-hour urine collection. Catheter insertion requires a licensed nurse to assess for complications and maintain sterile technique. Using a catheter when not indicated could increase the risk of infection and is not part of standard urine collection procedures.

C. Bringing a bucket of ice into the client’s bathroom shows that the UAP understands a critical aspect of 24-hour urine collection. Urine specimens must be kept cold during the collection period to prevent bacterial growth and chemical degradation, which ensures the accuracy and reliability of the laboratory results. This step is essential for maintaining specimen integrity over the entire 24-hour collection period.

D. Instructing the client to urinate directly into the specimen container for the first void is incorrect. The first void must be discarded, and the client’s urine for the remainder of the 24-hour period must be collected according to the protocol. Direct collection for the first void would compromise the accuracy of the test results.

A. Keep suction equipment at the bedside. B. Suggest the client use a straw to drink liquids. C. Encourage slow, small bites. D. Remain with the client during meals. E. Monitor for coughing while eating.

Correct Answer is ["A","C","D","E"]

Explanation

Rationale:

A. Keeping suction equipment at the bedside is appropriate. Clients on aspiration precautions are at risk for inhaling food, liquids, or secretions into the airway. Having suction readily available ensures rapid intervention if choking or aspiration occurs, promoting airway safety.

B. Suggesting the client use a straw to drink liquids is not appropriate. Using a straw can increase the speed and volume of liquid entering the mouth, which may raise the risk of aspiration in clients with swallowing difficulties. Therefore, this action should not be included in the plan of care unless specifically ordered by a speech-language pathologist.

C. Encouraging slow, small bites is correct. Small bites reduce the risk of choking and allow the client more time to chew and swallow safely. This helps minimize the risk of aspiration and improves swallowing control.

D. Remaining with the client during meals is appropriate. Close supervision allows the nurse to monitor swallowing ability, ensure proper positioning, and intervene quickly if signs of aspiration occur.

E. Monitoring for coughing while eating is correct. Coughing, choking, throat clearing, or a wet voice during meals are signs of possible aspiration. Early recognition allows for prompt intervention and prevention of complications such as aspiration pneumonia.

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The nurse cares for a group of clients who have topical medications ordered. Which client should the nurse see first?

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Naxlex Comprehensive Predictor Exams

The nurse delegates a 24-hour urine specimen collection to the unlicensed assistive personnel (UAP). Which action shows the UAP understands the urine collection process?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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