After change-of-shift report, which patient should the nurse assess first?

Correct Answer: D

Rationale: The correct answer is D. The nurse should assess the patient with a repaired right femoral shaft fracture complaining of tightness in the calf first. This could indicate a potential complication like deep vein thrombosis (DVT), which is a serious condition requiring immediate attention to prevent further harm. Assessing for DVT is crucial as it can lead to pulmonary embolism if left untreated. Choice A is incorrect as facial pain in a patient with a repaired mandibular fracture, while important, does not pose an immediate life-threatening risk. Choice B is incorrect as an externally rotated leg in a patient with an unrepaired intracapsular left hip fracture may indicate a hip dislocation, but it is not as urgent as assessing for a potential DVT. Choice C is incorrect as wrist swelling and deformity in a patient with an unrepaired Colles’ fracture, while concerning, does not require immediate attention compared to the potential complication of DVT in the patient with the femoral shaft

Correct Answer: A

Rationale: The correct answer is A: report the patient’s complaint to the surgeon. The numbness and tingling in the right lower leg could indicate nerve damage post-laminectomy with spinal fusion. It is crucial to inform the surgeon immediately to evaluate and address the issue promptly. Checking the preoperative assessment data (B) may not provide immediate insight into the current issue. Checking vital signs for hemorrhage (C) is important but not the priority in this scenario. Turning the patient to the left (D) would not address the underlying cause and could potentially worsen the symptoms. Reporting to the surgeon ensures timely intervention and prevents further complications.

Correct Answer: C

Rationale: The correct answer is C because discontinuing the use of sustained-release opioids is not appropriate for a patient with metastatic bone cancer of the left femur. This patient likely experiences severe pain that requires opioids for adequate pain management. Monitoring serum calcium levels (A) is essential due to the risk of hypercalcemia. Teaching about the need for strict bed rest (B) helps prevent fractures and reduces pain. Supporting the left leg when repositioning the patient (D) helps maintain alignment and prevent further damage.

Correct Answer: D

Rationale: The correct answer is D. The presence of diffuse lesions and skin sloughing on the client's mucous membranes is the greatest immediate threat in toxic epidermal necrolysis (TEN). This condition results in severe skin detachment, leading to increased risk of infection, fluid loss, and electrolyte imbalances. Skin sloughing can also affect mucous membranes, increasing the risk of respiratory compromise, sepsis, and systemic infection. The other choices are not the greatest immediate threat in TEN. Bacterial cellulitis (choice A) is a potential complication but not the most immediate threat. Fluid and electrolyte imbalances (choice B) are significant but secondary to the skin sloughing. A cascading autoimmune response (choice C) can occur in TEN but is not the immediate threat compared to the risk of mucous membrane involvement and skin sloughing.

Correct Answer: C

Rationale: The correct answer is C: Pulling the client up in bed. This action involves the greatest risk of skin shearing because it creates friction and shear forces on the skin, especially when the client is moved against the surface of the bed. This can lead to skin breakdown and pressure ulcers. Rolling the client from supine to side-lying position (B) and helping the client ambulate after surgery (D) can cause shear forces but to a lesser extent compared to pulling the client up in bed. Inserting a peripheral intravenous catheter (A) does not involve significant shear forces on the skin.