The nurse receives change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm sized dark red drainage.
A client who fell from a ladder and has a collapsed left lower lung with 100 ml drainage in a chest tube collection container.
A client who is post-mastectomy 2 days ago and has 50 ml of serosanguineous fluid in a Jackson-Pratt drain.
A client who had an abdominal perineal resection 3 days ago and has no drainage on the dressing and is reporting chills.
The Correct Answer is B
Choice A rationale: While the client with the gunshot wound requires attention, the client with a collapsed left lower lung and 100 ml drainage in a chest tube collection container is at immediate risk for respiratory compromise.
Choice B rationale: The client who fell from a ladder with a collapsed left lower lung and 100 ml drainage in a chest tube collection container requires the most immediate intervention to address potential respiratory distress.
Choice C rationale: The client post-mastectomy with 50 ml of serosanguineous fluid in a Jackson-Pratt drain may need attention, but the respiratory distress in the other client takes precedence.
Choice D rationale: The client who had an abdominal perineal resection with no drainage on the dressing and reporting chills may require attention, but the respiratory distress in the other client is a more urgent concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The client with a kidney transplant experiencing "flu-like" symptoms can be evaluated for urgency but may not require the first available appointment.
Choice B rationale: The client with non-radiating, low-back pain rated at 10 on a scale of 0 to 10 should be assessed, but it may not be an immediate concern compared to the other options.
Choice C rationale: The client at 3-weeks gestation with a small amount of bright red blood after passing stool requires evaluation, but it may not be as urgent as the client in Choice D.
Choice D rationale: The 2-year-old girl with a history of a "cold," tugging on her ear, and a fever of 102 F (38.9° C) may have an ear infection, which could be an acute problem requiring prompt evaluation.
Correct Answer is A
Explanation
Choice A rationale: This is because ceftriaxone is an antibiotic that can be administered by gravity drip without an IV pump, as long as the flow rate is monitored and adjusted manually.
Choice B rationale: Heparin in normal saline, especially for deep vein thrombosis, requires precise control of the infusion rate, making an infusion pump necessary.
Choice C rationale: Regular insulin in normal saline for ketoacidosis should be administered via an IV pump due to the need for precise control of the infusion rate.
Choice D rationale: Magnesium in normal saline for hypomagnesemia may also require careful control of the infusion rate, making an infusion pump preferable.
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