A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
Reference Range:
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl (10.8 mmol/L).
The client with an Ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
The Correct Answer is D
Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.
Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.
Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.
Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Asking the nurse to explain thoughts on the need for an in-service program encourages open communication and allows the nurse-manager to address specific concerns.
Choice B rationale: Choosing to send another nurse may not address the concerns of the nurse expressing dissatisfaction and may not promote a collaborative approach. Choice C rationale: Encouraging the nurse to share concerns and discuss ways to prepare for emergencies fosters open communication and allows for constructive dialogue.
Choice D rationale: Informing the nurse that in-service is not optional and attendance is mandatory may create resistance and does not promote a collaborative approach to addressing concerns.
Correct Answer is A
Explanation
Choice A rationale: The priority is to ensure the client's safety and comfort. If the client is restrained for bed linen change, alternative methods that don't involve wrist restraints should be considered. The nurse manager should advise the staff nurse to remove the restraints promptly.
Choice B rationale: Determining whether the client has a PRN prescription for an antianxiety agent is not the priority in this situation. The immediate concern is the use of restraints for a non-emergency purpose.
Choice C rationale: Contacting the healthcare provider to ensure a prescription for restraints was written may be needed, but the immediate concern is addressing the use of restraints for changing bed linens.
Choice D rationale: Closing the door to the room to avoid disturbing other clients is not the priority in this situation. The primary concern is the use of restraints for a non emergency purpose.
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