Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?

Correct Answer: D

Rationale: The correct answer is D because chills in a post-op patient could indicate the presence of infection, which is a serious concern post-surgery. The nurse should see this client first to assess for signs of sepsis. Choice A is incorrect as the small area of dark drainage in a gunshot wound client doesn't indicate immediate danger. Choice B is incorrect as the amount of fluid in the drain post-mastectomy is within normal limits. Choice C is incorrect as the absence of drainage in a collapsed lung client isn't an immediate priority compared to potential signs of infection in choice D.

Correct Answer: D

Rationale: The rule of nines is used to estimate the percentage of body surface area affected by burns. The upper trunk comprises 18% of the total body surface area, making it the largest single area. This is why choice D is the correct answer. The other choices are incorrect because the face and neck (choice A) represent 4.5%, the right upper arm and penis (choice B) represent 4.5%, and the right thigh and penis (choice C) represent 9%, which are all smaller percentages compared to the upper trunk.

Correct Answer: C

Rationale: The correct answer is C because in chronic renal failure (CRF), the kidneys are unable to effectively filter waste products from the blood, leading to elevated levels of blood urea nitrogen (BUN) and serum creatinine. BUN levels higher than 100 mg/dl and serum creatinine levels higher than 6.5 mg/dl indicate impaired kidney function, which is characteristic of CRF. A is incorrect because in CRF, pH tends to be decreased rather than increased due to metabolic acidosis. B is incorrect because in CRF, there is typically a buildup of potassium, magnesium, and calcium in the blood, not an increase in their serum levels. D is incorrect because uric acid levels and phenolsulfonphthalein excretion are not specific markers for CRF. Therefore, C is the correct answer based on the characteristic laboratory findings in chronic renal failure.

Correct Answer: A

Rationale: The correct answer is A: Turn him frequently. Turning the client frequently helps redistribute pressure, reducing the risk of pressure ulcers. This promotes circulation and relieves pressure on specific areas. Passive ROM exercises (B) are important for maintaining joint mobility but do not directly prevent pressure ulcers. Reducing fluid intake (C) is not recommended as hydration is crucial for skin health. Using a footboard (D) may help with positioning but is not as effective as regular turning for preventing pressure ulcers.

Correct Answer: C

Rationale: The correct order to anticipate for the female client with chest and stomach pain and black tarry stool is option C. Firstly, an electrocardiogram is necessary to assess for any cardiac issues related to the chest pain. Next, a complete blood count is essential to evaluate for any potential blood disorders causing the black tarry stool. Testing for occult blood helps identify any gastrointestinal bleeding. Lastly, a comprehensive serum metabolic panel provides a broad assessment of the client's overall health status. Option A is incorrect as creatine kinase and lactate dehydrogenase levels are not typically indicated for the presenting symptoms. Option B focuses on coagulation parameters, which are not the primary concern in this case. Option D includes tests unrelated to the client's symptoms, making it an inappropriate choice.