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%.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: A fitted respirator (N95 mask) is used for airborne precautions (e.g., tuberculosis), not droplet precautions like influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This is beyond the UAP’s scope of practice. Assessment and clinical judgment are the nurse’s responsibility.
C. Assign the UAP to provide care for another client and assume full care of the client: There is no indication that the UAP is incapable of providing care once properly instructed in precautions.
D. Review the need for the UAP to wear a face mask while in close contact with the client: Influenza is spread via respiratory droplets, so a surgical mask is required when within 3 feet of the client. This action ensures appropriate use of personal protective equipment (PPE).

A. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis. B. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis. C. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED use D. Assign the PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for the new admission

Correct Answer is ["D"]

Explanation

- Choice A Rationale: This choice is not optimal because the PN has the skills necessary to assist with the thoracentesis, a procedure that requires clinical judgment and skill, which the UAP does not possess. The RN is also needed to obtain the report from the ED due to the complexity of unstable angina, which requires advanced knowledge and assessment skills.

- Choice B Rationale: This option incorrectly assigns the UAP to prepare the room, which is within their scope, but fails to utilize the PN's skills effectively. The PN should be involved in more complex tasks such as assisting with procedures or obtaining detailed reports, rather than the UAP.

- Choice C Rationale: This choice is inappropriate because it assigns the UAP to assist with the thoracentesis, a task they are not trained for and is outside their scope of practice. The RN should be involved in the more complex care of obtaining the report, and the PN should assist with the thoracentesis.

- Choice D Rationale: This is the correct choice because it utilizes all staff members according to their scope of practice and skills. The PN assists with the thoracentesis, a task they are qualified for, the RN obtains the report on the new admission, which requires advanced knowledge, and the UAP prepares the room, a task that fits their role.

- Choice E Rationale: As there is no Choice E provided in the question, no rationale can be given for this option. It is important to follow the instructions and options given in the scenario to provide accurate and relevant information.

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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)]

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Naxlex Comprehensive Predictor Exams

A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["D"]

Explanation

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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)]