A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
A client who has COPD and the capillary refill time on both hands is 4 seconds
A client who has late-stage cirrhosis and whose breath has a fruity odor
A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
The Correct Answer is D
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
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Correct Answer is B
Explanation
Rationale:
A. Hospice care focuses on comfort and quality of life, not on curing the illness. Therefore, the oncologist would typically shift focus to palliative care.
B. Managing symptoms such as dyspnea is a primary aspect of hospice care, aimed at improving the quality of life.
C. Hospice care is usually for patients with a prognosis of six months or less, not for those with indefinite life expectancy.
D. Hospice care can be provided in various settings, including the patient’s home, not just long-term care facilities.
Correct Answer is D
Explanation
Rationale:
A. HICS focuses on organizing and managing internal facility operations rather than mobilizing external multidisciplinary responders.
B. HICS does not directly ensure the availability of specific medical supplies; this is usually managed through other systems or protocols.
C. HICS is primarily concerned with internal facility management, not providing additional responders from outside agencies.
D. HICS helps to define roles, responsibilities, and reporting channels within the facility during a disaster, ensuring effective internal management.